KADIMA REHABILITATION & NURSING AT HARMONY
For profit - Limited Liability company
115 Beds
KADIMA HEALTHCARE GROUP
Data: November 2025
2 Immediate Jeopardy citations
Trust Grade
0/100
#586 of 653 in PA
Photo by The Grove at Harmony
Photo by The Grove at Harmony
Photo by The Grove at Harmony
1 / 5 photos
Last Inspection: May 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Kadima Rehabilitation & Nursing at Harmony has received a Trust Grade of F, indicating significant concerns about the facility's quality of care. It ranks #586 out of 653 nursing homes in Pennsylvania, placing it in the bottom half, and #9 out of 11 in Butler County, meaning only two homes in the area perform worse. Although the facility is improving, with issues decreasing from 44 in 2024 to 22 in 2025, the staffing situation is concerning, as the turnover rate is 68%, well above the state average of 46%. The facility has incurred $173,281 in fines, which is higher than 95% of Pennsylvania facilities, suggesting ongoing compliance issues. Additionally, there have been critical incidents, such as a resident suffering a severe fall due to inadequate supervision, and another resident eloping from the facility without proper monitoring, highlighting serious safety concerns despite having average staffing ratings and some RN coverage.
- Trust Score
- F
- In Pennsylvania
- #586/653
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 68% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ○ Average
- $173,281 in fines. Higher than 67% of Pennsylvania facilities. Some compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 30 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 77 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 11%
Review needed
44 → 22 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 44 issues
2025: 22 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Pennsylvania average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 68%
22pts above Pennsylvania avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $173,281
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: KADIMA HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (68%)
20 points above Pennsylvania average of 48%
The Ugly 77 deficiencies on record
2 life-threatening
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
Deficiency F0603
(Tag F0603)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, observations and resident and staff interviews, it was revealed that the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, observations and resident and staff interviews, it was revealed that the facility failed to prevent involuntary seclusion for one of six residents reviewed (Resident R5).
Findings include:
Review of the facility policy Abuse Protection reviewed 4/25/25, indicated the resident has the right to be free from verbal, physical, mental abuse, neglect, corporal punishment, and involuntary seclusion. Abuse means the infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. Involuntary seclusion is defined as separation of a resident from other residents from his/her room or confinement to his/her room against the resident's will.
Review of the Resident Rights reviewed 4/25/25, indicated the resident has the right to a dignified existence and self-determination. The facility will protect and promote the rights of each residents. Residents are to be treated with dignity and respect.
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 2024, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:
13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment
Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE], with diagnoses that included anxiety, depression, and psychotic disorder.
Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 5/24/25, indicated the diagnoses were current. Further review of the MDS, Section C: Cognitive Patterns; Question C0500 BIMS Summary Score indicated 15. Section GG: Functional Abilities; Question GG0170 Mobility D: indicated the resident was dependent-helper does all of the effort.
During an observation on 6/12/24, at 12:05 p.m. Resident R5's door was closed and was heard yelling open my door repeatedly. LPN, Employee E1 was observed opening Resident R5's door and stated Don't shut her door. Nurse Aide (NA), Employee E2 stated I shut her door because she is screaming at me. She sits there and tells me what to do. LPN, Employee E1 confirmed NA, Employee E2 closed Resident R5's door.
During an interview on 6/12/25, at 12:08 p.m. Resident R5 stated NA, Employee E2 knows not to shut the door. Resident R5 indicated the door was shut for about five minutes. Resident R5 stated NA, Employee E2 shut the door because the food tray cart was open and NA, Employee E2 was on their phone.
During an interview on 6/12/25, at 12:16 p.m. NA, Employee E2 stated Resident R5 was screaming to get off the phone and pass the lunch trays. NA, Employee E2 confirmed she closed Resident R5's door.
During an interview on 6/12/25, at 12:55 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to prevent involuntary seclusion for one of six residents (Resident R5).
28 Pa. Code 201.14(b) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(2)(3) Management.
28 Pa. Code 211.10(a)(c.)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
May 2025
21 deficiencies
1 IJ
CRITICAL
(J)
📢 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
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, resident interview, and staff interviews, it was deter...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, resident interview, and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision that resulted in an elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54). This failure created an immediate jeopardy situation for two of 108 residents.
Findings include:
Review of facility policy Resident Elopement dated 4/25/25, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leaves of absence) and/or any necessary supervision to do so. Upon admission, residents will be assessed for elopement risk. Cognitively impaired residents with the physical ability to leave the facility without assistance, and who have demonstrated or vocalized a desire to leave the facility will be placed on a unit with an electronic monitoring system or similarly secured unit. Residents at risk for elopements shall have their pictures maintained for identification purposes. Residents at high risk for elopement shall not be admitted to the facility unless appropriate interventions are identified prior to admission and the facility has the ability to appropriately supervise and monitor the resident.
Review of the clinical record indicated Resident R110 was admitted to the facility on [DATE].
Review of Resident R110's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/16/25, indicated diagnoses of high blood pressure, delirium due to known physiological condition, and altered mental status.
Review of Resident R110's clinical record revealed an Elopement Risk Assessment completed on 3/10/25, which consisted of the following information:
Risk Assessment:
1) Is the resident cognitively impaired? Yes
2) Is the resident independently mobile (ambulatory or wheelchair)? Yes
3) Does the resident have poor decision-making skills? Yes
4) Has the resident demonstrated exit seeking behavior? Yes
5) Does the resident wander oblivious to safety needs? Yes
6) Does the resident have a history of elopement? No
Determination:
1) Resident is determined AT RISK for elopement. Yes
2) Plan has been implemented to ensure resident safety. Yes
Score: 1.0 Category: At Risk for Elopement
Review of Resident R110's care plan dated 3/11/25, indicated the resident will not wander out of facility through next review. Interventions included assist in reorientation to room and facility using verbal cues and reminders, check resident's whereabouts frequently, door alarms on at all times and answer alarms promptly, encourage group activity and attempt to keep occupied, make receptionist and other staff aware of elopement risk, notify social services for persistent attempts to leave building and not responding to redirection, photo identification on file in front lobby, put familiar items in resident's room to assist in identifying room, redirect from exits as needed based on behavior, and Wanderguard device (electronic monitoring safety bracelet) check placement and function each shift.
Review of a physician order dated 3/11/25, indicated Wanderguard every evening shift check for proper function.
Review of a physician order dated 3/11/25, indicated Wanderguard every shift check for proper placement.
Review of an event submitted by the facility dated 3/24/25, stated, On 3/24/25 at approximately 1930 (7:30 p.m.) the Supervisor was made aware that Resident R110 was unintentionally let out by a CNA (Certified Nurse Aide). While the CNA was attending to another resident and helping them through the doorway, Resident R110 walked outside and away from CNA to another location of facility grounds. CNA was alerted that the resident walked away and immediately alerted the Supervisor. The Supervisor immediately alerted other staff to search facility grounds. Within two minutes, staff from the facility Personal Care (PC) side called the Supervisor to make her aware that Resident R110 was found knocking on their front door. Addendum - when code is entered, and the door is opened the wanderguard system does not alarm. In this instance when the staff member entered the code and opened the door to allow residents outside, Resident R110 was not close enough to the door to allow the system to alarm prior to the staff opening the door.
Review of a nursing progress note dated 3/24/25, stated, Resident was let out with smokers and walked around building to door. PC called to make staff aware of situation. Floor staff went to PC to bring resident back to unit. CNA educated on the importance of knowing who can't go out at smoke times. Resident willingly returned to unit and had no injuries or distress noted.
Review of a witness statement completed by Registered Nurse (RN) Employee E14 dated 3/25/25, stated, Last night on 3-11 shift, this RN was notified by staff that Resident R110 had followed the smoking residents out the door with staff for their smoke break. In less than two minutes, PC staff notified this staff that he was outside, and he was immediately accompanied into the building. He was pleasant and courteous with staff, fully assessed, VSS (vital signs stable), and Resident R110 was in good spirits. His wander guard was checked along with all doors, and he was supervised at all times, as one of the residents also noticed his walking out with the smokers and alerted the group. Physician and family notified.
Review of a witness statement dated 3/25/25, completed by Nurse Aide (NA) Employee E5 stated, I was taking the residents out for smoking break and another resident, Resident R110, walk passed while I was tending to another resident while getting her out the door way. In the midst of assisting that resident over to the rest of the residents another resident informed me that Resident R110 had taken off walking away from the facility building. I instantly started running to see where he was, I didn't see him so I ran inside the building asking the nurses for help because Resident R110 had walked off. At that moment everyone set out to find out where Resident R110 had gone to.
Review of a Current Smokers list provided by the facility on 5/5/25, indicated the facility has 12 residents who smoke. Resident R110 was not identified by the facility as a current smoker.
During an observation on 5/6/25, at 10:37 a.m. seven residents were observed in the designated smoking area with one staff member. During this observation, while staff had the door open to allow residents outside, the wanderguard system continuously alarmed while the door was held open.
During an interview on 5/6/25, at 10:44 a.m. RN Employee E13 stated, We don't have any documentation that we bring with us during smoking, we just know who smokes. They're never all out at once.
During an observation on 5/6/25, at 11:18 a.m. of an Elopement Binder located at the nurse's station revealed Residents R104, R106, and R110 were identified as elopement risks.
During an interview on 5/6/25, at 11:23 a.m. NA Employee E2 stated, I just started in March. The facility gave me education about their elopement policy. I know residents are an elopement risk because they have one of those bracelets. I'm not sure about a binder with elopement risks. Resident R106 tries to get out, she's the only one I know for sure.
During an interview on 5/6/25, at 11:25 a.m. NA Employee E1 stated, Therapy approves smokers for safety. There is no list used for smokers, we basically know who smokes. There are too many smokers to go outside with just one person watching. When asked who elopement risks are, NA Employee E1 stated, Her and pointed to Resident R54. NA Employee E1 stated, She got outside one time with visitors about a week ago. We couldn't find her in the building another time, we all had to look for her.
Review of the clinical record revealed that Resident R54 was admitted to the facility on [DATE].
Review of Resident 54's MDS dated [DATE], indicated diagnoses of high blood pressure, chest pain, and dementia (a progressive decline in mental ability, impacting memory, thinking, language, and behavior, to the point where it affects daily life).
Review of Resident R54's clinical record revealed an Elopement Risk Assessment completed on 4/8/25, which consisted of the following information:
Risk Assessment:
1) Is the resident cognitively impaired? Yes
2) Is the resident independently mobile (ambulatory or wheelchair)? Yes
3) Does the resident have poor decision-making skills? Yes
4) Has the resident demonstrated exit seeking behavior? Yes
5) Does the resident wander oblivious to safety needs? Yes
6) Does the resident have a history of elopement? No
Determination:
1) Resident is determined AT RISK for elopement. Yes
2) Plan has been implemented to ensure resident safety. Left Blank
Score: 1.0 Category: At Risk for Elopement
Review of Resident R54's clinical record revealed a physician's order dated 4/8/25, for a Wanderguard, which was discontinued on 4/15/25.
During an observation on 5/6/25, at 11:26 a.m. Resident R54 was observed pushing on an external door and asked State Agency how to get out of the door.
During an interview on 5/6/25, at 11:45 a.m. NA Employee E3 stated, Resident R54 has exit seeking behaviors. Coworkers informed me she got out the front door with visitors about a week ago. I have to redirect her often. She does not have a Wanderguard.
An additional review of Elopement Binder on 5/6/25, at 11:50 a.m. confirmed that Resident R54 was not identified as an elopement risk.
During an interview on 5/6/25, at 11:55 a.m. the Nursing Home Administrator (NHA) stated he was not aware that Resident R54 had gotten out of the building or if she was an elopement risk.
During an interview on 5/6/25, at 12:11 p.m. the Director of Nursing (DON) stated, When Resident R54 was admitted we were told by a nurse who had Resident R54 at a prior facility that she was an elopement risk. When she was admitted , we put her as an elopement risk and put a Wanderguard on her. We watched her for a week, and she did not communicate any wants to leave, so we discontinued her Wanderguard. Elopement assessments are done at admission and quarterly. Staff are to notify the supervisor if there is a change in a resident's behavior. The Activity Director updates the elopement binder anytime there is a change. Elopement risks are reviewed daily, it's part of our clinical stand-up meeting.
On 5/6/25, at 1:45 p.m., the NHA and DON were made aware that Immediate Jeopardy (IJ) existed, NHA was provided the IJ Template, for two of 108 residents, which resulted in an elopement from the facility, and a corrective action plan was requested.
During a telephonic interview on 5/6/25, at 2:43 p.m. NA Employee E5 stated, I was letting the smokers out and he [Resident R110] must have gotten by me and I really didn't notice. One of the other residents was like, the guy left and the resident told me who it was. I immediately went to the front of the building, couldn't find him, went back in and told nurses. We never found him; he went to personal care. He got out in the midst of letting the smokers out, I was helping a resident over the little hump of the door, she couldn't push herself over in her wheelchair. He must have went around me and I didn't notice. The facility had previously given me education about elopements. At the time of the incident, I didn't know he was a wanderer.
During an observation on 5/6/25, at 3:53 p.m. Resident R54 was observed attempting to get out of the facility through an external door. The Wanderguard system alarmed when Resident R54 approached the door, alerting staff of her attempt to exit the building.
On 5/6/25, at 4:02 p.m. an acceptable Corrective Action Plan was received which included the following interventions:
Immediate Action:
- The facility immediately reviewed and revised the elopement policy on 5/6/25, at 2:00 p.m.
Residents:
- The Director of Nursing or designee will complete assessments on all residents to identify their risk for elopement on 5/6/25, and care plans will be updated to reflect the residents' current condition, risk for elopement and resident centered interventions on 5/6/25. A list of residents at risk for elopement will be placed at each nursing station to inform staff of residents at risk.
System Correction:
- The root cause of the elopement has been determined to be lack of staff education and supervision.
- The Nursing Home Administrator or Designee will educate all staff, including agency staff, on elopement policies and procedures, documenting residents with exit seeking behaviors, reporting exit seeking behaviors to administration and implementing proper interventions for these residents prior to staff's next scheduled shift.
- The facility immediately will allocate additional staff members to supervise smokers to ensure appropriate supervision is available to meet residents. The facility will immediately have one staff member for every eight residents who smoke.
Monitoring:
- The Facility will complete a head count of all residents each shift for four weeks to ensure residents are safe and provided adequate supervision.
- The Director of Nursing of Designee will review progress notes daily for four weeks to identify any residents with new exit seeking behaviors to ensure appropriate interventions are in place.
- The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for frequency of audits.
The facility's policy and procedures for elopements were reviewed on 5/6/25, no revisions were made. The facility's policy and procedures for smoking were reviewed and revised on 5/7/25, to reflect supervision of one staff member for every eight residents during supervised smoking.
During an observation on 5/7/25, at 10:38 a.m. six residents were observed outside smoking with three staff members present.
On 5/7/25, at 11:20 a.m. it was confirmed 108/108 residents were reassessed for an elopement risk. 4/108 residents were identified as at risk, and 4/4 care plans were updated to include interventions to prevent elopement. 4/4 residents were included in the elopement binders.
Elopement books with 4/4 identified residents were observed at two of two nursing stations and the front desk. The residents' photos and names were listed.
Review of facility documents on 5/7/25, revealed that the facility has 126 employees and that 100% had received elopement education. 59 of these employees received formal education on the policy Resident Elopement which included reporting residents with exit seeking behaviors to the supervisor and documenting all exit seeking behaviors in the clinical record. 67 of these employees had received education via telephone as they had not been working in the building. Staff are to sign when they are in the building before the start of their next shift.
During employee interviews on 5/7/25, from 9:58 a.m. through 11:55 a.m. 36 employees confirmed they had received education on the facility's elopement policy and procedures, as stated above.
The Immediate Jeopardy was lifted on 5/7/25, at 12:07 p.m. when the action plan implementation was verified.
During an interview on 5/7/25, at 12:08 p.m. the NHA confirmed that the facility failed to make certain each resident received adequate supervision that resulted in an elopement for one resident (Resident R110) and failed to properly identify a resident's risk for elopement (Resident R54). This failure created an immediate jeopardy situation for two of 108 residents who may not have been identified properly as an elopement risk.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on review of observations and staff interview, it was determined that the facility failed to protect and value residents' private space (South Wing Resident R18, and R63)
Findings include:
Revi...
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Based on review of observations and staff interview, it was determined that the facility failed to protect and value residents' private space (South Wing Resident R18, and R63)
Findings include:
Review of the facility policy Confidentiality dated 4/25/25, indicated that to protect resident's privacy and dignity, the staff should not enter rooms without knocking except in an emergency.
During an observation on South Wing on 5/5/25, at 12:03 p.m. Nurse Aide (NA) Employee E1 was seen entering Resident 18's room without knocking or requesting permission to enter.
During an observation on South Wing on 5/5/25, at 12:05 p.m. Nurse Aide (NA) Employee E1 was seen entering Resident 63's room without knocking or requesting permission to enter.
During an interview on 5/5/25, at 12:05 p.m. NA Employee E1 confirmed that she failed to knock prior to entering Resident R18, and R63's rooms which failed to protect and value the residents' private space.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 201.29(a)Resident Rights.
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 facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medicat...
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Based on review of facility policy, observation, and staff interview it was determined that the facility failed to maintain the confidentiality of residents' medical information on one of five medication carts (North Medication Cart).
Findings include:
Review of facility policy Confidentiality dated 4/25/25, indicated the resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Access to resident medical records will be limited to the staff and consultants providing services to the resident.
During an observation on 5/6/25, at 11:20 a.m. the North Medication Cart at the nurses station was left unattended with the computer screen open with identifiable information any passerby could see resident personal and confidential information.
During an interview on 5/6/25, at 11:20 a.m. Registered Nurse Employee E4 confirmed the above observation and that the facility failed to maintain the confidentiality of residents' medical information as required.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.29(c.3) Resident Rights.
28 Pa. code: 211.5(b) Medical records.
28 Pa. Code: 211.12(d)(1)(3) 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview, it was determined that the facility failed to maintain a clean, safe, and homelike environment for three of ten residents (Resident R106, R102, and R64).
Findings Include:
Review of the facility policy Resident Environment dated 4/25/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment.
During observations of the North nursing unit on 5/5/25, at 9:45 a.m. the following was observed:
-Resident R106 in room [ROOM NUMBER]-D, indicated the perimeter of the wall to the left of the entrance door was dirty with built up grime, the floor mat beside the bed was dirty with white and gray markings and smudges, the perimeter of the wall under the heating element was corroded with built up grime, the bathroom had five visibly cracked floor tiles.
-Resident R102 in room [ROOM NUMBER]-D, indicated a bathroom with three visibly cracked floor tiles around the base of the commode.
-Resident R64 in room [ROOM NUMBER]-B, indicated gnats flying around the bedside table that had an old meal tray from breakfast still there. The perimeter of the wall under the heating element was corroded with built up grime, and there was an air condition unit sitting on the floor in the corner of the room.
Tour and interview with the Nursing Home Administrator (NHA), on 5/5/25, at 10:05 a.m. the NHA confirmed the facility failed to maintain a clean, safe, and homelike environment for three of ten residents (Resident R106, R102, and R64).
28 Pa. code: 201.14 (b) Responsibility of licensee.
28 Pa Code: 201.18 (e)(1)(2) Management.
28 Pa Code: 201.29 (a)(c) Resident Rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from mental abuse and threats of punishment or deprivation for one of three residents reviewed (Resident R64).
Findings include:
The facility's policy Abuse Protection dated 4/25/25, indicated each resident has the right to be free from abuse. Abuse means the infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Mental abuse includes, but is not limited to, humiliation, harassment, and threats of punishment or deprivation, denial of food or privileges.
Review of admission record indicated Resident R64's was admitted to the facility on [DATE].
Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/25, indicated the diagnoses of chronic atrial fibrillation (irregular heart rhythm), mechanical complications of an internal fixation device of bones, and chronic pain. Section C indicated a BIMS score of 15 (Brief Interview for Mental Status - a screening test that aides in detecting cognitive impairment). A total score of 13 -15, indicated cognitively intact.
Review of Resident R64's care plan on 5/9/25, at 12:30 p.m. indicated resident has pain related to osteoarthritis (flexible protective tissue at the ends of bones, cartilage, wears down and worsens over time), lymphedema (swelling in arm or leg caused by a lymphatic system blockage), chronic osteomyelitis (inflammation of bone caused by infection), and mechanical complication of internal fixator device of bone. Goal indicated the pain will be resolved within one hour of intervention. Administer pain medications per physician order and note the effectiveness. Acknowledge presence of pains and discomfort. Listen to resident's concerns.
Review of Resident R64's physician orders indicated the following medications for pain;
-Order dated 2/12/25, indicated gabapentin (medication for chronic nerve pain) 300 milligrams (mg) three times daily.
-Order dated 4/16/25, indicated acetaminophen (medication that treats mild aches and pain) 650mg every eight hours.
-Order dated 4/17/25, indicated oxycodone (a potent narcotic for pain)/acetaminophen 7.5mg/325mg every six hours.
Review of Resident R64's medication administration record indicated resident was receiving medications as prescribed.
Observation of Resident R64 on 5/5/25, at 10:00 a.m. indicated resident lying in bed with a visibly enlarged and disfigured left ankle wrapped heavily in an ACE wrap (elastic bandages).
Interview on 5/5/25, at 10:00 a.m. Resident R64 indicated he injured his left ankle over four years ago and has had terrible pain and complications ever since. Resident indicated the doctors here won't give me my medicines every four hours and that he really needed them every four hours as the terrible pain returns too soon with the medications being every six hours.
Review of Certified Registered Nurse Practitioner (CRNP) Employee E17's palliative care consultation dated 5/7/25, at 1:41 p.m. indicated Reason for Palliative Consultation chronic pain from osteomyelitis of left foot/ankle, debility and behavioral disturbance.
Further review of CRNP Employee E17's consultation indicated Resident R64's mood was stable that morning, although he did have a verbal outburst with aggression/chair throwing over the weekend. Resident was upset with staff that his pain medication was not given 30 minutes early as staff had competing priorities. CRNP Employee E17 indicated I discussed at length with resident that it is never ok to treat staff that way, we do not tolerate verbal abuse and will reduce pain medications in future if this behavior persists.
Interview on 5/9/25, at 10:48 a.m. the Assistant Director of Nursing (ADON) Employee E10 and the Nursing Home Administrator were notified by survey agency of the CRNP Employee E17's palliative consultation and the intimidation, threatening to decrease pain medications as mental abuse and threats of punishment or deprivation of services.
Interview on 5/9/25, at 10:49 a.m. the NHA confirmed that the consultation note indicated a form of intimidation and threatening to deprive Resident R64 of pain medications was not appropriate.
Interview on 5/9/25, at 1:30 p.m. the NHA confirmed the facility failed to make certain a resident was free from mental abuse and threats of punishment or deprivation for one of three residents reviewed (Resident R64).
28 Pa. Code 201.14(b) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(2)(3) Management.
28 Pa. Code 211.10(a)(c.)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident records, facility documentation, incidents submitted to the local State field offic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident records, facility documentation, incidents submitted to the local State field office, resident council interview, resident and staff interviews it was determined that the facility failed to submit a report of an allegation of emotional abuse in a timely manner to the local State field office for one of five sampled residents (Resident R96).
Findings include:
The facility Abuse reporting and investigation policy dated 11/1/24 and last reviewed 4/25/25, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse. Abuse includes the deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Mental abuse includes humiliation, harrassment, threats of punishment, or deprivation. Department of Health will be notified of an alleged event by the Administrator.
Review of Resident R96's admission record indicated that he was originally admitted on [DATE].
Review of Resident R96's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 2/2/25, indicated that he had diagnoses that included hypertension (a condition impacting blood circulation through the heart related to poor pressure), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning).
Review of Resident R96's care plans dated 5/6/25, indicated to gently redirect activities when Resident R96 makes inappropriate actions.
Review of Resident R96's Nurse practitioner note dated 4/25/25, indicated that Resident 96 stated his mood is ok and he began complaining about some issues such as bathroom had poop all over it and sometimes they are mean to me referring to staff.
Review of Resident R96's clinical nurse progress note dated 4/25/25 , indicated that at 8:28 p.m. Resident R96 was screaming profanities and racial slurs at staff. Staff approached resident in hallway by his room asked him to stop yelling and he continued to yell about the staff. Staff escorted him to his room and offered emotional support he was not accepting of support and told staff to get the f out of his room. Staff left his room and he then slammed the door.
Review of Resident R96's clinical nurse progress note dated 4/25/25 , indicated that at 9:33 p.m. Resident R96 continued to come out of his room and verbally attack staff. He was witnessed on the floor in the hallway and he was screaming profanities and racial slurs; he stated that he is going to call the police on staff. He then began to throw the battery to the hoyer lift at staff. Emotional support was offered but he replied with f- you. He then went to the end of west hall in his wheelchair and was trying to pull the fire alarm. Staff called EMS and the police for assistance. Police arrived and Resident R96 calmed down and voluntarily went with EMS to hospital for a psychological evaluation.
Review of Resident R96's Nurse practitioner note dated 4/29/25, indicated that Resident R96 was observed in his wheelchair. He sated they still don't treat me right referring to staff. He further stated they pick on me. I ask them for things and they taunt me. Resident R96 had significant behaviors on Saturday which required a 911 call and transfer to the hospital for evaluation.
During a resident council group interview on 5/7/25, at 1:02 p.m. Resident R53 voiced a concern with staff to resident intimidation.
During an interview on 5/8/25, at 9:43 a.m. Resident R53 stated the following: yes, there was an incident. It occurred next to us. There was a bathroom problem. Older gentleman had issues; it was Resident R96. It does not take much to trigger him. The bathroom was cleaned around 5:00 p.m. to 6:00 p.m. The bathroom was a mess again and an African-American female agency aide was asked to clean it and she refused. Resident R96 got mad and threw food. Then they (Resident R96 and the unidentified staff person) started swearing back and forth at one another. Resident R96 was later sent to the hospital to evaluate for mental illness. The toilet was not cleaned until the next day. The people here know about it.
During an interview on 5/8/25, at 9:52 a.m. information relayed to Nursing Home Administrator (NHA) and the NHA stated that it sounded familiar and he will provide documentation.
Review of reports and facility documents submitted to the local State field office from 2/1/25 to 5/7/25 did not include a report related to Resident R96's allegation of emotional abuse.
During an interview on 5/8/25, at 1:09 p.m. the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility failed to submit a report of an allegation of emotional abuse in a timely manner to the local State field office involving Resident R96 as required.
28 Pa Code: 201.18 (e)(1)(2) Management
28 Pa Code: 201.29 (a )(c)(d) Resident Rights
28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0628
(Tag F0628)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents sampled with facility-initiated transfers (Residents R3, and R110).
Findings include:
Review of the admission record indicated Resident R3 was admitted to the facility on [DATE].
Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/28/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood).
Review of the clinical record indicated Resident R3 was transferred to the hospital on 4/28/25.
Review of Resident R3's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
Interview with the Director of Nursing on 5/9/25, at 10:00 a.m. confirmed Resident R3's clinical record did not contain the required information prior to transferring to the hospital.
Review of the clinical record indicated Resident R110 was admitted to the facility on [DATE].
Review of Resident R110's MDS dated [DATE], indicated diagnoses of high blood pressure, delirium due to known physiological condition, and altered mental status.
Review of the clinical record indicated Resident R110 was transferred to the hospital on 4/12/25.
Review of Resident R110's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
During an interview on 5/9/25, at 11:55 a.m. the Assistant Director of Nursing (ADON) Employee E10 confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for two of three residents as required.
28 Pa. Code: 201.29 (a)(c.3)(2) Resident rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation and interviews it was determined that the facility failed to provide care and se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation and interviews it was determined that the facility failed to provide care and services to meet the accepted standards of clinical practice two of four residents (Resident R14 and R16).
Findings include:
A review of the facility policy Controlled Medications dated 4/25/25, indicated when a controlled drug is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record: date and time of administration, amount administered, signature of the nurse administering the dose, completed after the dose is actually administered.
Observation of medication storage on 5/7/25, at 12:42 p.m. of the North Medication Cart, it was discovered that the random narcotic count for accurate record keeping was inaccurate.
Interview on 5/7/25, at 12:43 p.m. Licensed Practical Nurse (LPN) Employee E6 indicated, the count is not going to be correct, because I gave the medications this morning. I signed them on the medication administration record (MAR), but not yet on the narcotic accountability record.
Review of admission Record indicated Resident R14 was admitted to the facility on [DATE].
Review of Resident R14's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/16/25, indicated diagnoses of high blood pressure, anxiety and depression.
Review of Resident R14's physician order dated 4/8/25, indicated to give clonazepam (a controlled substance that treats anxiety) 0.5 milligrams (mg) three times daily.
Review of Resident R14's MAR for 5/7/25, indicated the clonazepam was signed off by LPN Employee E6 as administered per orders.
Observation and interview with LPN Employee E6 on 5/7/25, at 12:44 p.m. Resident R14's card of clonazepam had 47 pills in it and the narcotic accountability log indicated there should have been 48 pills, due to LPN Employee E6 not immediately documenting it after it was given.
Review of admission Record indicated Resident R16 was admitted to the facility on [DATE].
Review of Resident R16's MDS dated [DATE], indicated the diagnoses of heart failure (heart does not pump blood as well as it should), high blood pressure, and anxiety.
Review of Resident R16's physician order dated 12/31/24, indicated lorazepam (a controlled substance that treats anxiety) 0.5mg three times daily.
Review of Resident R16 MAR for 5/7/25, indicated the lorazepam was signed off by LPN Employee E6 as administered per orders.
Observation and interview with LPN Employee E6 on 5/7/25, at 12:46 p.m. Resident R16's card of lorazepam had 20 pills in it and the narcotic accountability log indicated there should have been 21 pills, due to LPN Employee E6 not immediately documenting it after it was given.
During an interview 5/7/25, at 2:00 p.m. the Director of Nursing confirmed that the facility failed to provide care and services to meet the accepted standards of clinical practice two of four residents (Resident R14 and R16).
28 Pa. Code 211.10(a)(c.)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to follow a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to follow a physician order for an edema (swelling) glove for one out of three residents (Resident R35).
Findings include:
Review of the facility policy Quality of Care: Attain and Maintain dated 4/25/25, indicated each resident must receive and the facility will provide the necessary services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
Review of the admission record indicated Resident R35 was admitted on [DATE].
Review of Resident R35's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/29/25, indicated the diagnoses of high blood pressure, stroke (damage to the brain from an interruption of blood supply), and seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness).
Review of Resident R35's physician order dated 2/21/25, indicated
resident to wear right edema glove on with morning care off with evening care.
Review of Resident R35's care plan dated 4/3/25, indicated resident to wear right edema glove on with morning care off with evening care.
Observation on 5/7/25, at 1:00 p.m. Resident R35 was out of bed in the wheelchair, dressed and ready for the day without the edema glove to his right hand as ordered.
Observation on 5/9/25, at 10:00 a.m. Resident R35 was out of bed in the wheelchair, dressed and ready for the day without the edema glove to his right hand as ordered.
Interview on 5/9/25, at 10:05 a.m. Nurse Aide (NA) Employee E18 indicated it was her normal assignment and nobody on that hall (North Hall) had a glove for edema or swelling.
Interview on 5/9/25, at 10:09 a.m. NA Employee E19 indicated it was her normal assignment and nobody on that hall (North Hall) had a glove for edema or swelling.
Interview on 5/9/25, at 10:30 a.m. Licensed Practical Nurse (LPN) Employee E6 confirmed on the computer that Resident R35 was ordered to have a right-hand edema glove on and confirmed he did not have it on as ordered.
Interview on 5/9/25, at 1:30 p.m. the Director of Nursing confirmed the facility failed to follow a physician order for an edema glove for one out of three residents (Resident R35).
28 Pa. Code 201.18(b)(1)(2)(3) Management.
28 Pa. Code 211.10(a)(c.)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
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 and resident and staff interviews, it was determined that the facility...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records and resident and staff interviews, it was determined that the facility failed to make certain that residents receive proper treatment and assistive devices to maintain visual ability for one of four residents (Resident R41).
Findings include:
Review of the facility policy Vision and Hearing dated 4/25/25, indicated the facility will ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities.
Interview on 5/6/25, at 9:40 a.m. Resident R41 asked survey agency to read the menu for lunch as he could not read it. Resident indicated he used to have glasses but has not had a pair in a long time.
Review of the admission record indicated Resident R41 was admitted to the facility on [DATE].
Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/25, indicated the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), stroke (damage to the brain from an interruption of blood supply), and depression. Section B1200 corrective lenses indicated Yes.
Review of Resident R41's eye care chart note dated 11/30/23, indicated resident presents for evaluation of cataracts (clouding of the normally clear lens of the eye) in the right and left eye. It affects both eyes and the symptom is constant. The condition is moderate. No treatment at this time, monitor for progression. New glasses will be ordered pending insurance/payer approval.
Review of Resident R41's eye care chart note dated 8/15/24, indicated the assessment showed age-related nuclear cataract of both eyes. Plan - after education and discussion, the patient would like to be referred out for cataract surgery. Return to clinic in two to four months for follow up.
Review of Resident R41's progress note dated 10/8/24, indicated resident returned back from ophthalmology appointment in stable condition but unable to be seen due to insurance issues as per physician's office.
Review of Resident R41's optometry note dated 3/10/25, indicated cancelled visit. Resident did not have cataract surgery and does not need to be seen.
Interview on 5/8/25, at 1:00 p.m. Assistant Director of Nursing (ADON) Employee E10 verified that resident had not had cataract surgery and did not have glasses.
Interview on 5/9/25, at 1:30 p.m. the Director of Nursing confirmed the facility failed to make certain that residents receive proper treatment and assistive devices to maintain visual ability for one of four residents (Resident R41).
28 Pa. Code: 211.10(a)(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(3)(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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, observations, and staff interviews, it was determined that the facility failed to ensure a resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility for one of five residents (Resident R2).
Findings include:
Review of facility policy Splint/Brace Management dated 4/25/25, indicated residents will be assessed to determine a splint/brace device program to attain, maintain, and prevent decline in joint mobility.
Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].
Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/30/25, indicated diagnoses of high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and muscle weakness.
Review of a physician order dated 1/31/25, indicated resident to wear bilateral (both sides) palm roll splints (a brace used to prevent finger contractures and skin break down in the palm) at all times, remove for hygiene and perform skin checks every shift.
During an observation on 5/6/25, at 10:47 a.m. Resident R2 was observed without her bilateral palm roll splints applied.
During an observation on 5/7/25, at 10:50 a.m. Resident R2 was observed without her bilateral palm roll splints applied.
During an observation on 5/7/25, at 1:20 p.m. Resident R2 was observed without her bilateral palm roll splints applied.
During an interview on 5/7/25, at 1:25 p.m. Licensed Practical Nurse Employee E6 confirmed Resident R2 did not have her palm roll splints applied and that the facility failed to ensure Resident R2 received appropriate services, equipment, and assistance to maintain or improve mobility.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10(a)(c)(d) Resident care policies.
28 Pa. Code: 211.12(c)(d)(1)(2)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for two of two residents (Residents R11 and R89).
Findings include:
Review of facility policy Side Rails Proper Use dated 4/25/25, indicated an assessment will be made to determine the resident's symptoms or reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's bed mobility and ability to transfer between positions, to and from bed or chair, to stand and toilet. The use of quarter or half-side rails, as an assistive device will be addressed in the resident care plan.
Review of the clinical record indicated Resident R11 was admitted to the facility on [DATE].
Review of Resident R11's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/24/25, indicated diagnoses of high blood pressure, hyponatremia (low levels of sodium in the blood), and depression.
During an observation on 5/5/25, at 11:32 a.m. two top enabler bars were present on Resident R11's bed.
Review of Resident R11's clinical record on 5/7/25, failed to include an ongoing assessment for the resident's enabler bar usage, and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan.
Review of the clinical record indicated Resident R89 was admitted to the facility on [DATE].
Review of Resident R89's MDS dated [DATE], indicated diagnoses of hyperkalemia (high levels of potassium in the body), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and depression.
During an observation on 5/5/25, at 10:30 a.m. two top enabler bars were present on Resident R89's bed.
Review of Resident R89's clinical record on 5/7/25, failed to include an ongoing assessment for the resident's enabler bar usage, and failed to include the development of goals and interventions related to the resident's enable bar usage in the care plan.
During an interview on 5/8/25, at 2:21 p.m. the Assistant Director of Nursing Employee E10 confirmed that the facility failed to maintain accurate resident care plans and conduct ongoing accurate assessments to ensure that bedrails were used to meet residents' needs and the risks associated with bedrail usage for two of two residents as required.
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)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident records, a facility tour, and staff interview it was determined that the facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident records, a facility tour, and staff interview it was determined that the facility failed to follow transmission based precautions and utilize enhanced barrier precautions (EBP) creating the potential for cross contamination for two out of five sampled residents (Residents R79 and R92).
Findings include:
The facility Infection control policies and procedure: enhanced barrier precautions policy dated 4/1/24 and last reviewed 4/25/25, indicated that enhanced barrier precautions are an infection control intervention designed to reduce transmission of multi-drug resistance organisms (MDRO) in nursing homes. Enhanced barrier precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those with increased risk such as residents with wounds or indwelling medical devices. Indwelling medical devices include central lines, urinary catheters, feeding tubes and tracheostomies.
Review of Resident R79's admission record indicated she was originally admitted on [DATE].
Review of Resident R79's MDS assessment (MDS: Minimum Data Set assessment-a periodic assessment of resident care needs) dated 3/20/25, indicated she had diagnoses that included breast and lung cancer, chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and hyperlipidemia (elevated lipid levels within the blood).
Review of Resident R79's physician orders dated 3/14/25, indicated to use 16-French foley catheter, change foley catheter bag, and to utilized enhanced barrier precautions.
Review of Resident R79's care plans dated 3/17/25, indicated to utilize enhanced barrier precautions as ordered.
During observations on 5/5/25, at 11:00 a.m. Resident R79 was observed in her room. She was observed with a catheter in place. Observations of her room and door did not include a Enhanced barrier precautions (EBP) signage or infection control gown and gloves.
During observations on 5/5/25, at 11:31 a.m. Resident R79 was observed in her room. She was observed with a catheter in place. Observations of her room and door did not include a Enhanced barrier precautions (EBP) signage or infection control gown and gloves.
During observations on 5/8/25, at 9:54 a.m. Resident R79 was observed in her room. She was observed with a catheter in place. Observations of her room and door did not include a Enhanced barrier precautions (EBP) signage or infection control gown and gloves. Resident R79 catheter bag was observed on the floor.
During observations with Registered Nurse (RN) Employee E16 on 5/8/25, at 10:18 a.m. Resident R79 was observed in her room. She was observed with a catheter in place. Observations of her room and door did not include a Enhanced barrier precautions (EBP) signage or infection control gown and gloves. Resident R79 catheter bag was observed on the floor.
During an interview on 5/8/25, at 10:19 a.m. Registered Nurse (RN) Employee E16 stated there is no sign on the door and yes, the bag is on the floor.
Review of the admission record indicated Resident R92 admitted to the facility on [DATE].
Review of Resident R92's MDS dated [DATE], indicated the diagnoses of high blood pressure, obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed, either structurally or functionally), and pyelonephritis (kidney infection).
Review of Resident R92's physician order dated 3/17/25, indicated cleanse nephrostomy tube (a thin catheter inserted into the kidney to drain urine when normal flow is blocked or obstructed) drain site with normal sterile saline and apply drain sponge every day and to utilize enhanced barrier precautions.
Review of Resident R92's care plan dated 3/19/25, indicated resident has a nephrostomy tube, use enhanced barrier precautions.
Observation of Resident R92 on 5/8/25, at 1:37 p.m. indicated resident in his wheelchair, with catheter drainage bag, covered under the chair. The doorway did not include signage indicating enhanced barrier precautions.
Interview on 5/8/25, at 2:00 p.m. Infection Preventionist Employee E22 confirmed Resident R92's doorway was not adorned with appropriate signage for enhanced barrier precautions as required.
During an interview on 5/8/25, at 11:20 a.m. Assistant Director of Nursing (ADON) Employee Employee E10 was asked how is EBP is communicated and stated: we have signs on doors for precautions and there is an overhead with isolation garb, masks, gloves and equipment. We discuss who is on isolation during standup in the morning.
During an exit interview on 5/9/25, at 1:30 p.m. information was disseminated to the Director of Nursing (DON) and Nursing Home Administrator (NHA) that the facility failed to follow transmission based precautions and utilize enhanced barrier precautions (EBP) creating the potential for cross contamination for Residents R79 and R92.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.28 (b)(1)(e )(1) Management.
28 Pa Code: 211.10 (d ) Resident care policies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Smoking Policies
(Tag F0926)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policy and resident and 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 clinical records, facility policy and resident and staff interviews, it was determined that the facility failed to follow the policies established to assess one of twelve residents for safe smoking practices (Resident R64).
Findings include:
Review of the facility Smoking Policy dated 4/25/25, stated (1) upon admission, residents who smoke will be reviewed for safety with independence in smoking (2) licensed staff or department managers will be responsible for completion of the resident smoking review upon admission(3) All smoking will be . (5) All smokers who are capable of understanding the rules and regulations will be asked to sign a smoking agreement to demonstrate their understanding of the rules concerning smoking. (7) smokers will be reviewed on admission, quarterly and as necessary depending on individual circumstances and changes in the resident's condition.
Review of the admission record indicated Resident R64 admitted to the facility on [DATE].
Review of Resident R64's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/18/25, indicated the diagnoses of chronic atrial fibrillation (irregular heart rhythm), mechanical complications of an internal fixation device of bones, and chronic pain. Section J1300 indicated current tobacco use as No.
Review of Resident R64's physician orders on 5/9/25, at 9:02 a.m. failed to include orders relating to smoking.
Review of Resident R64's smoking evaluation dated 2/18/25, indicated resident was not a smoker.
Review of Resident R64's care plan indicated resident is at risk for side effects from smoking and should wear a smoking apron when actively smoking.
Interview on 5/5/25, at 10:00 a.m., Resident R64 indicated that he smoked, and the smoking times were at 8:30 a.m., 10:30 a.m., 1:30 p.m., 4:00 p.m., 7:00 p.m., and 9:00 p.m.
Interview on 5/9/25, at 10:56 a.m. Assistant Director of Nursing Employee E10 confirmed that there was not a physician order for Resident R64 to smoke and the smoking evaluation on 2/18/25, was not completed correctly to reflect resident's smoking status.
Interview on 5/9/25, at 1:30 p.m. the Director of Nursing confirmed the facility failed to follow the policies established to assess one of twelve residents for safe smoking practices (Resident R64).
28 Pa. Code 201.14(b) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(2)(3) Management.
28 Pa. Code 211.10(a)(c.)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for four of ten residents (Residents R2, R55, R74, and R89).
Findings include:
Review of facility policy MDS/RAI/Care Planning dated 4/25/25, indicated the Resident Assessment Instrument (RAI) and Care Planning Process provide a tool for interdisciplinary approach to plan the care of the resident. The purpose of the RAI is to incorporate the identified medical, nursing, nutritional, rehabilitative, and psychosocial needs of each resident into interventions and goals to meet those needs. The RAI is a process that defines an interdisciplinary approach to resident assessment and plan of care to help the resident attain the highest practicable functional level.
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 October 2024, indicated the following instructions:
- Section A1500: Preadmission Screening and Resident Review (PASRR): code 1, yes if: PASSR Level II screening determined that the resident has a serious mental illness and/or ID/DD (Intellectual Disability/Developmental Disability) or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions.
- Section J1300: Current Tobacco Use: code 1, yes if: the resident or any other source indicates that the resident used tobacco in some form during the 7-day look-back period.
- Section N0415: High-Risk Drug Classes: Use and Indication, Question N0415E1 - Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 day).
Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].
Review of Resident R2's quarterly MDS dated [DATE], indicated diagnoses of high blood pressure, schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior), and muscle weakness.
Review of Resident R1's Preadmission Screening Resident Review Identification (PASRR-ID) Level 1 form, dated 1/5/17, indicated the resident has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II).
Review of a letter from The Department of Human Services, dated 1/4/17, indicated Resident R2 had evidence of a Mental Health condition that meets criteria for review by the Office of Mental Health and Substance Abuse Services.
Review of Resident R2's annual comprehensive MDS dated [DATE], Question A1500 Preadmission Screening and Resident Review (PASRR) indicated no the resident is not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition.
During an interview on 5/8/25, at 10:58 a.m. Social Service Director Employee E20 confirmed Resident R2 is considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition.
Review of the clinical record indicated Resident R55 was admitted to the facility on [DATE].
Review of Resident R55's admission MDS dated [DATE], indicated diagnoses of high blood pressure, schizophrenia, and depression. Question A1500 Preadmission Screening and Resident Review (PASRR) indicated no the resident is not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. Question J1300 indicated the resident was coded 0 No for Current Tobacco Use.
Review of Resident R55's Preadmission Screening Resident Review Identification (PASRR-ID) Level 1 form, dated 1/31/25, indicated the resident has a positive screen for Serious Mental Illness, Intellectual Disability, and/or Other Related Condition; requires further evaluation (Level II).
Review of a letter from The Department of Human Services, dated 2/14/25, indicated Resident R55 had evidence of a Mental Health condition that meets criteria for review by the Office of Mental Health and Substance Abuse Services.
During an interview on 5/8/25, at 10:58 a.m. Social Service Director Employee E20 confirmed Resident R55 is considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition.
Review of a physician order dated 4/15/25, indicated OK to smoke per facility protocol.
Review of Resident R55's Smoking Safety Screening assessment dated [DATE], indicated the resident smokes 5-10 cigarettes a day and was safe to smoke with direct supervision.
Review of a nursing progress note dated 4/15/25, stated, While out smoking this evening, the resident was arguing with another resident about the Vietnam War, insisting that he was fighting against Americans. This caused quite a disruption in the smoking time for residents as there are veterans in the group. The CNA (Certified Nurse Aide) that took them out reported that this resident kept getting louder and more aggressive with his argument.
Review of the clinical record indicated Resident R74 was admitted to the facility on [DATE].
Review of Resident R74's quarterly MDS dated [DATE], indicated diagnoses of high blood pressure, anxiety, and muscle weakness. Question N0415E1 indicated the resident received an anticoagulant during the 7-day look-back period.
Review of Resident R74's clinical record failed to include a physician order for an anticoagulant medication.
Review of the clinical record indicated Resident R89 was admitted to the facility on [DATE].
Review of Resident R89's quarterly MDS dated [DATE], indicated diagnoses of hyperkalemia (high levels of potassium in the body), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and depression. Question N0415E1 indicated the resident received an anticoagulant during the 7-day look-back period.
Review of Resident R89's clinical record failed to include a physician order for an anticoagulant medication.
During an interview on 5/9/25, at 10:56 a.m. Licensed Practical Nurse Assessment Coordinator Employee E9 confirmed that the facility failed to ensure that Minimum Data Se assessments accurately reflected the resident's status for four of ten residents as required.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 211.5(f) Medical records.
28 Pa. Code 211.12(c)(d)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records and staff interviews, it was determined that the facility failed to provide sufficient a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical records and staff interviews, it was determined that the facility failed to provide sufficient and timely social services related to assistance in obtaining guardians for two of four residents (Resident R41 and R102).
Findings include:
Review of the facility's Social Service Job Description indicated the social worker will develop a community resource file and establishes contact with new providers. Refer resident/family member to appropriate social service agencies when facility does not provide services or needs of resident.
Review of the admission record indicated Resident R41 was admitted to the facility on [DATE].
Review of Resident R41's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/12/25, indicated the diagnoses of Alzheimer ' s Disease (a progressive disease that destroys memory and other important mental functions), stroke (damage to the brain from an interruption of blood supply), and depression. Section C- Brief Interview for Mental Status (BIMS - is a screening test that aides in detecting cognitive impairment) indicated a score of two: severe cognitive impairment.
Interview on 5/8/25, at 1:00 p.m. Assistant Director of Nursing (ADON) Employee E10 verified that resident had not had cataract surgery and did not have glasses because he had problems with the grandson, and he needed a guardian.
Interview on 5/8/25, at 1:10 p.m. the Nursing Home Administrator indicated the previous company quit paying the attorneys and they were in the process of establishing a new contract with another and verified there was a delay in getting Resident R41 a guardian.
Review of the admission record indicated Resident R102 was admitted to the facility on [DATE].
Review of Resident R102's MDS dated [DATE], indicated the diagnoses of manic depression (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), psychotic disorder (a mental disorder characterized by a disconnection from reality), and borderline intellectual functioning. Section C - Brief Interview for Mental Status indicated a score of three: severe cognitive impairment.
Upon admission agreement sign in review process on 5/9/25, it was discovered that Resident 102's admission sign in agreement was not completed from 7/19/24.
Interview on 5/9/25, at 11:00 a.m. the Nursing Home Administrator indicated Resident R102 is also on the list for needing a guardian and did not currently have one and confirmed the admission agreement sign in was never completed, and provided a General Notes Report on Resident R102 that indicated the following:
-7/22/24, Medical Assistance 103 admission sent (MA 103 must be completed by the facility or the resident's attending physician when a medical assistance applicant is admitted to the facility or converts to medical assistance, and when services are no longer required).
-8/9/24, Received CAO (County Assistance Office) request for more information.
-8/15/24, application sent without documents.
-9/4/24, denial received need resources and a complete application. Needs appealed by 9/25/24.
-9/20/24, Appeal sent to CAO
10/9/24, Rep payee (a representative payee is someone appointed by the Social Security Administration (SSA) to manage Social Security benefits for individuals who are unable to manage their own money) sent
10/22/24, Resident needs a guardian. Need all resources. Resident cannot sign. Was at a personal care home that closed.
11/26/24, received approval 11/21/24.
5/8/25, spoke to private vendor about guardianship. Private vendor will reach out to law firm to file a petition for guardianship.
Interview on 5/9/25, at 1:30 p.m. the Nursing Home Administrator confirmed the facility failed to provide sufficient and timely social services related to assistance in obtaining guardians for two of four residents (Resident R41 and R102)
28 Pa. Code 201.14(b) Responsibility of licensee.
28 Pa. Code 201.18 (b)(1)(3)(e)(1) Management.
28 Pa. Code 201.29 (a) Resident rights.
28 Pa. Code 211.16 (a)(1) Social services.
28 Pa. Code 211.12(d)(1)(3)(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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly se...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to properly secure a medication cart while not in use for one of five medication carts (North Medication Cart), and failed to properly store medications on three of three medication carts (North Medication Cart, North [NAME] Medication Cart, and Split Hall Medication Cart).
Findings include:
Review of facility policy Storage of Medications dated [DATE], indicated medications are stored in a safe, secure, and orderly manner in accordance with federal and state regulations and facility policies. Compartments containing medications are locked when not in use.
During an observation on [DATE], at 12:42 p.m. of the North Hall Medication Cart indicated the following medications not dated upon opening or expired:
-Resident R112's albuterol nebulizer (a medication used to prevent and treat narrowing of the airways in the lungs)
-Resident R72's timolol eye drops (used for glaucoma) were dated [DATE], and should have been expired by 28 days and discarded.
-Resident R12's albuterol nebulizer
-Resident R7's albuterol nebulizer
Interview on [DATE], at 12:43 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the medications were not dated upon opening or expired.
During an observation on [DATE], at 8:49 a.m. the North Medication Cart was observed outside of resident room [ROOM NUMBER] with the cart unlocked and unattended.
During an interview on [DATE], at 8:52 a.m. Registered Nurse (RN) Employee E7 confirmed the North Medication Cart was unlocked and unattended and that the facility failed to properly secure a medication cart while not in use.
During an observation on [DATE], at 9:13 a.m. of the North [NAME] Hall Medication Cart indicated the following medication not dated upon opening or expired:
-Resident R29's albuterol nebulizer
Interview on [DATE], at 9:13 a.m. LPN Employee E21 confirmed the medication was not dated upon opening as required.
During an observation on [DATE], at 11:14 a.m. of the Split Hall Medication Cart indicated the following medications not dated upon opening:
- Resident R33's Albuterol inhaler
- Resident R73's Albuterol inhaler
During an interview on [DATE], at 11:14 a.m. LPN Employee E8 confirmed the above observations and that the facility failed to properly store medications in the Split Hall Medication Cart.
Interview on [DATE], at 1:30 p.m. the Director of Nursing confirmed the facility failed to properly secure a medication cart while not in use for one of five medication carts (North Medication Cart), and failed to properly store medications on three of three medication carts (North Medication Cart, North [NAME] Medication Cart, and Split Hall Medication Cart).
28 Pa. Code: 201(a) Responsibility of licensee.
28 Pa. Code: 211.9(a)(1)(k) Pharmacy services.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected most or all residents
Based on observations, and staff interviews it was determined the facility failed to ensure that daily nutritional and special dietary needs for residents were met for one of four weeks (April/May 202...
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Based on observations, and staff interviews it was determined the facility failed to ensure that daily nutritional and special dietary needs for residents were met for one of four weeks (April/May 2025).
Findings include:
During an observation in the South Wing on 5/5/25, at 12:08 p.m. lunch trays were observed to not have any tray tickets on the trays to identify the resident, diet, or food items.
During an interview on 5/5/25, at 12:08 p.m. Nurse Aide (NA) Employee E1 stated that there have not been any tray tickets on trays for about a week, and that Dietary Staff have hand-written the residents' last name, room number, and diet order on the corner of the placemat on the trays.
During an interview on 5/5/25, at 12:15 p.m. Dietary Manager (DM) Employee E15 confirmed that the facility had a broken printer for approximately one week, and that the facility had not been utilizing tray tickets during that time frame, and that dietary staff was writing the residents' name, diet order, and room number on the placement. When DM Manager Employee E15 was asked how dietary staff was made aware of the information to write on the placemat, DM Employee E15 produced a printout that contained each residents' name, room number, and diet order. It did not contain food allergies, or preferences. DM Employee E15 confirmed that the facility failed to ensure that proper information regarding resident preferences and food allergies were communicated and provided.
During an interview on 5/5/25, at 12:20 p.m. DM Employee E15 informed that the printer is now working and that tray tickets would now be utilized.
During an interview on 5/5/25, at 1:32 p.m. Nursing Home administrator confirmed that the facility failed to ensure that daily nutritional and special dietary needs for residents were met.
28 Pa. Code: 201.12(d)(5) Nursing services
28 Pa. Code: 201.18(b)(1)(e)(1) Management
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 observations and staff interviews, it was determined that the facility failed to properly label and date food products, monitor and maintain records of refrigeration/freezer temperature logs ...
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Based on observations and staff interviews, it was determined that the facility failed to properly label and date food products, monitor and maintain records of refrigeration/freezer temperature logs to make certain refrigeration/freezers function properly, and failed to maintain the cleanliness and sanitation of equipment in the Main Kitchen. (Main Kitchen).
Findings include:
During an observation in the Main Kitchen on 5/5/25, at 9:44 a.m. refrigeration/freezer temperature log on tray line refrigerator, revealed that the facility failed to monitor and record temperatures on 5/2/25, 5/3/25, 5/4/25, and 5/5/25. Observation also revealed that refrigeration/freezer temperature log on walk-in refrigerator, and walk-in freezer revealed that the facility failed to monitor and record temperatures on 5/3/25, and 5/4/25.
During an observation on 5/5/25, at 9:45 a.m. in the walk-in refrigerator the following items were observed to have no label or date:
·
Plastic container of cooked beef patties
·
Plastic container of pickles
·
Plastic container of diced potatoes
·
Plastic container of sauerkraut
·
Plastic container of Jello
·
Bag of coleslaw mix
During an observation on 5/5/25, at 9:46 a.m. in the cook's area a plastic container of Cheerios was observed with no label or date.
During an observation in the Main Kitchen on 5/5/25, at 9:49 a.m. the meat slicer was observed to not have a cover in place to protect from contamination.
During an observation in the Main Kitchen on 5/5/25, at 9:50 a.m. the stand mixer was observed to not have a cover in place to protect from contamination, and contained a thick layer of dried food particles.
During an interview on 5/5/25, at 9:51 am the Dietary Manager Employee E15 confirmed that the facility failed to properly label and date food products, monitor and maintain records of refrigeration/freezer temperature logs, and failed to maintain the cleanliness and sanitation of equipment in the Main Kitchen.
Pa Code 201.14(a) Responsibility of licensee.
Pa Code 201.18(b)(3) Management.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage t...
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Based on review of job descriptions, clinical records and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to effectively manage the facility to prevent the elopement of a resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54), which created an Immediate Jeopardy situation for two of 108 residents.
Findings include:
The job description for the Nursing Home Administrator specified the primary purpose of the job position is to manage the Facility with current applicable federal, state, and local standards, guidelines, and regulations that govern long-term care facilities To follow all facility policies and apply them uniformly to all employees. The ensure the highest degree of quality care is provided to our residents at all times.
The job description for the Director of Nursing specified the purpose of the job is to plan, organize, develop and direct the overall operation of the Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times.
Based on findings identified in this report, the facility failed to prevent the elopement of a resident (Resident R110), and failed to properly identify a resident's risk for elopement (Resident R54), which placed the residents in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed.
During an interview on 5/7/25, at 12:08 p.m. the NHA and DON confirmed that they failed to effectively manage the facility to prevent the elopement of a resident and failed to properly identify a resident's risk for elopement, which created an Immediate Jeopardy situation.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0575
(Tag F0575)
Minor procedural issue · This affected most or all residents
Based on observations and staff interview it was determined that the facility failed to have required postings for the facility in areas that are accessible to all residents throughout the facility fo...
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Based on observations and staff interview it was determined that the facility failed to have required postings for the facility in areas that are accessible to all residents throughout the facility for State Agency information, how to file a complaint with State Agency, Adult Protective Service information, and complete contact information for State Long-Term Care Ombudsman program posted at the facility.
Findings include:
During an observation on 5/8/25, at 12:42 p.m. in the [NAME] Hallway there was a poster with Ombudsman contact information, which only consisted of the phone number, and did not have name, address, or email address listed.
During an observation on 5/8/25, at 12:44 p.m. at the nursing station between the South Hallway and North Hallway, failed to include information on State Agency, how to file a complaint with State Agency, and Adult Protective Services.
During an observation on 5/9/25, at 9:47 a.m. in the Northwest Hallway, failed to include information on State Agency, how to file a complaint with State Agency, and Adult Protective Services.
During an interview on 5/9/25, at 11:12 a.m. the Nursing Home Administrator confirmed that the facility failed to have required postings in areas that are accessible to all residents throughout the facility for State Agency information, how to file a complaint with State Agency, Adult Protective Services information, and complete contact information for State Long-Term Care Ombudsman program.
28 Pa. Code: 201.14(a)Responsibility of licensee.
28 Pa. Code: 201.18(b)(3) Management.
Dec 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
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 policy, shower schedule documents, resident clinical records, resident and staff interviews, it was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, shower schedule documents, resident clinical records, resident and staff interviews, it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for one of seven sampled residents (Resident R1).
Findings include:
The facility Flow of care policy dated 2/1/24, indicated that care will be provided to residents, as needed 24-hour a day to attain and maintain the highest level of functioning. The flow of care is to be implemented on a continuous basis to promote quality of life with the resident. The provision of targeted care needs shall be documented on Care Tracker (electronic record), Point of Care (electronic record), or ADL (Activity of Daily Living) Flow Records. The 7 a.m. -3 p.m. shift may provide the following: oral hygiene, toileting, breakfast, and showers/baths. The 3 p.m.- 11 p.m. shift may provide the following: Evening meal, repositioning, hydration, and bath/showers.
Review of facility shower schedule documentation indicated that Resident R1 showers are scheduled for Tuesdays and Fridays during the 3 p.m. to 11 p.m. shift.
Review of Resident R1's admission record indicated he was admitted [DATE].
Review of Resident R1's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/22/24, indicated he had diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), hyperlipidemia (elevated lipid levels within the blood), and hypertension (a condition impacting blood circulation through the heart related to poor pressure). The diagnoses were found current upon review.
Review of Resident R1's care plan indicated that he was risk for functional decline in ADL's and to monitor skin integrity during baths/showers as
Review of Resident R1's shower documentation indicated there was no shower provided the week of 12/1/24 to 12/7/24.
Review of Resident R1's clinical nurse progress notes did not indicate he was provided a shower or refused a shower the week of 12/1/24.
During an interview on 12/12/24, at 11:04 a.m. Resident R1 stated: They are a little short on staff in the evenings. I get an aide to help me in the shower. I did miss one shower.
During an interview on 12/12/24, at 12:40 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide Activity of Daily Living (ADL) assistance with showers for Resident R1 as required.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(6) Management.
28 Pa. Code: 201.20 Staff development.
28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.
Nov 2024
2 deficiencies
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to notify the physician of missed medication and increased behaviors for one of four residents (Resident CRR2) and failed to notify a resident's responsible party for an increase in medication dosage for one of three residents (Resident R1).
Review of the facility's policy Notification Change in Condition Responsible Party dated 2/1/24, indicated the responsible party or guardian is to be notified of changes in condition or occurrences to ensure that the resident ' s responsible party or guardian is notified of changes and /or occurrences and action and pertinent information are documented. When any one of the following instances occurs, the resident's responsible party or guardian will be notified including but not inclusive to: There is a significant change in the resident's physical, mental or psychosocial status. An incident has occurred, (including falls, altercations, injuries, elopements, medication errors, etc.).
Refusal of medications, treatments, labs. The nurse must document the name of the person notified, the date and time in the nurse's notes.
Review of the facility's policyNotification of Condition Change Physician Notification dated 2/1/24, indicated licensed professional nurses are responsible to provide timely and complete communication to physicians when there is a change in a resident's condition. Document assessment data the attempted or actual correspondence with physician, and physician's response in the medical record.
Review of Resident CRR2 indicated an admission date of 10/19/24.
Review of Resident CRR2's Minimum Data Set (MDS) dated [DATE], indicated the diagnosis of hypertension (high blood pressure), hyperlipidemia (high fat in the blood), and dementia (impairment of memory and thinking). Section C0200 indicated Brief Interview for Mental Status (BIMS- is a screening test that aides in detecting cognitive impairment) The BIMS total score suggests the following distributions: 13-15: cognitively intact; 8-12: moderately impaired; 0-7: severe impairment. Resident CRR2 received a score of three indicating severe impairment.
Review of Resident CRR2's admission elopement indicated resident was at risk for elopement.
Review of Resident CRR2's progress note dated 11/5/2024, at 07:48 indicated resident approached this nurse stating, I don't want your food, I don't want any of your pills. I want that doctor here right now. You people are keeping me from Altoona. I want my sister. If I don't get to Altoona, I am going to hurt somebody. Resident was pacing the hallway, very agitated. He went back into his room and sat on the bed staring at the door. Supervisor and DON notified of resident's agitated state.
Review of CRR2's progress notes indicate on 11/5/24, at 8:59 a.m. resident is refusing to take any and all medications.
Review of progress note dated 11/5/2024, at 9:45 a.m. indicated resident in the hallway walking back to room from nurse's station. Resident informed this nurse that the man that is in his room is not helping him to get to Altoona and he wants him out of there. The resident stated, If you don't get him out I will. I don't want him in my house. While speaking, he was making a fist and clearly showing this nurse that he is agitated. He was assured that the roommate was not going to hurt him and that this nurse would talk to the supervisors about removing him from the room. Resident shook head.
Review of progress note dated 11/5/2024 at 11:45 a.m. indicated resident remains agitated. Sitting on the bed staring at the door. Resident is unapproachable at this moment. Resident refused lunch and is continuing to ramble about seeing a doctor to get back to Altoona. Resident states, Call the Altoona police and send me to the prison. Either way I am going to Altoona. My sister is . I want the doctor here, they won't call my sister, I need to go to Altoona. Resident reassured that he may call his sister whenever he wants to. Resident stated, Get out of my room until you get the doctor and a ride to Altoona hospital. Someone's gonna get hurt.
During an interview completed on 11/22/24, at 12:05 p.m. Director on Nursing confirmed that the physician was not notified of Resident CRR2's refusal of medications and increase in behaviors.
During an interview completed on 11/22/24, at 12:20 p.m. the Assistant Director of Nursing (ADON) stated it is poor documentation and confirmed that failed to notify the physician of missed medication and increased behaviors for one of four residents (Resident CRR2).
Review of Resident R1's clinical record indicate an admission date of 10/31/24.
Review of Resident R1's minimum Data Set (MDS) dated [DATE], indicates the diagnosis of hypertension (high blood pressure), urinary tract infection, and dementia (impairment of memory and thinking) Section C0200 indicated Brief Interview for Mental Status (BIMS- is a screening test that aides in detecting cognitive impairment) The BIMS total score suggests the following distributions: 13-15: cognitively intact; 8-12: moderately impaired; 0-7: severe impairment. Resident R1 received a score of seven indicating severe impairment.
Review of physician orders dated 11/18/2024, indicate Remeron Oral Tablet 30 MG (Mirtazapine-medication used to treat depression and can also help with sleep) Give 1 tablet by mouth every hour of sleep.
Review of progress note on 11/18/2024, at 4:40 p.m. indicate Nurse Practitioner (NP) in to see resident and ordered to increase Mirtazapine to 30mg PO QHS for anxiety/insomnia. Resident aware and will continue to be monitored.
During an interview on 11/21/24, at 1:23 p.m. the ADON Employee E1 confirmed that Resident R1 has a BIMS score of 7 and that her responsible party was not notified of an increase in her medication we will have to educate the nurse and that the facility failed to notify a resident's responsible party for an increase in medication dosage for one of three residents (Resident R1).
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 201.29(a)(c)(d)(j) Resident Rights.
28 Pa. Code 211.10(c)(d) Resident Care Policies.
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
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 facility policy, clinical records, observations, and staff interviews it was determined that the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, observations, and staff interviews it was determined that the facility failed to make certain each resident received adequate supervision which resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident CRR2) and failed to consistently document in the clinical record regarding post-incident response after an elopement for two of four residents (Resident R1 and CRR2).
Findings include:
Review of the facility's policy Elopement Prevention dated 2/1/24, indicated cognitively impaired residents at risk for elopement will be appropriately monitored to reduce the potential for injury. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so.
Review of the facility's policy Notification Change in Condition Responsible Party dated 2/1/24, indicated the responsible party or guardian is to be notified of changes in condition or occurrences to ensure that the resident ' s responsible party or guardian is notified of changes and /or occurrences and action and pertinent information are documented. When any one of the following instances occurs, the resident ' s responsible party or guardian will be notified including but not inclusive to: There is a significant change in the resident ' s physical, mental or psychosocial status. An incident has occurred, (including falls, altercations, injuries, elopements, medication errors, etc.). Refusal of medications, treatments, labs. The nurse must document the name of the person notified, the date and time in the nurse ' s notes.
Review of the facility's policy Notification of Condition Change Physician Notification dated 2/1/24 indicated licensed professional nurses are responsible to provide timely and complete communication to physicians when there is a change in a resident ' s condition. Document assessment data attempted or actual correspondence with physician, and physician ' s response in the medical record.
Review of Resident R1's clinical record indicate an admission date of 10/31/24.
Review of Resident R1's minimum Data Set (MDS) dated [DATE], indicates the diagnosis of hypertension (high blood pressure), urinary tract infection, and dementia (impairment of memory and thinking).
Review of Residents R1's facility provided information labeled privileged and confidential-not part of the medical record-do not copy indicated at approximately 2:30 p.m. when the second shift staff were arriving it was noted that the resident was standing at the end of the driveway.
Review of Resident R1's progress notes failed to have documentation regarding the incident of elopement the last documentation discovered in the clinical record was dated 11/1/24, followed by documentation completed on 11/2/24 at 3:00 p.m. that indicated progress note late entry: Head to toe assessment completed on resident, which revealed no redness, bruising, or open areas, able to move all extremities at baseline, vital signs stable, neuro checks within normal limits. Resident has no complaints of pain or discomfort.
During an interview on 11/21/24, at 11:47 a.m. the Director of Nursing stated, I don't know why the nurse didn' t document on Resident R1.
Review of Resident CRR2 indicated an admission date of 10/19/24.
Review of Resident CRR2's MDS dated [DATE], indicated the diagnosis of hypertension (high blood pressure), hyperlipidemia (high fat in the blood) and dementia.
Review of Resident CRR2's admission elopement indicated resident was at risk for elopement.
Review of Residents CRR2's facility provided information labeled witness statements dated 11/5/24, indicated at approximately 2:00 p.m. the nurse went back to resident CRR2's room to complete a 15-minute check and he was not in his room. At approximately 2:05 p.m. it was noted that the window in CRR2's room was open, and the screen was forcefully pushed out. Search was immediately expanded to the outside grounds of facility. Local authorities were notified, and communication from the local authorities stated they had located the resident and were going to bring him back to facility.
Review of Resident CRR2's progress notes failed to have documentation regarding the incident of elopement the last documentation discovered in the clinical record was dated 11/5/24 at 11:45 a.m. followed by a note dated 11/5/24, at 3:10 p.m. indicating a head-to-toe assessment completed. Noted superficial abrasion to top back of scalp 1cm x 1 cm no active bleeding, right elbow light bruising 3cm x 3 cm, right hip superficial abrasion 5cm x 5 cm no active bleeding, left knee superficial abrasion 0.5 x 0.5cm no active bleeding. Full range of motion to all extremities. Denies any pain at this time with movement. Denies chest pain or headache.
During an interview on 11/21/24 at 1:20 p.m. the Director of nursing stated upon asking if Resident CRR2 had adequate supervision replied I can't say I disagree to there being a lack of supervision and that facility failed to make certain each resident received adequate supervision that resulted in one elopement (resident exits to an unsupervised or unauthorized area without the facility's knowledge) for one of four residents (Resident CRR2) and failed to document in the clinical record regarding post-incident response after an elopement for two of four residents (Resident R1 and CRR2).
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing Services.
Jul 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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to obtain a physician's order fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to obtain a physician's order for a discharge and make certain that the necessary resident information was communicated to the receiving health care provider for one out of five residents sampled with facility-initiated transfers (Resident R1).
Findings include:
Review of facility policy Documentation of Resident Discharge dated 2/1/24, indicated that documentation will be completed when a resident is discharged form this facility. The following items are to be documented when a resident is discharged from the facility to home or another facility:
- Resident current condition, including mental status
- Physician's discharge order has been obtained
- Transfer form, facesheet, history, and physical
- Physician current orders and completed testing
Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 6/5/24, indicated diagnoses of high blood pressure, muscle spasms, and multiple sclerosis (a disease that affects central nervous system).
During a review of the clinical record indicated Resident R1 was transferred to an Inpatient Rehabilitation Center on 7/25/24.
During a review of Resident R1's clinical record on 7/31/24, at 12:05 p.m. failed to reveal a physician order for discharge to an inpatient rehabilitation center on 7/25/24.
During a review of Resident R1's clinical record on 7/31/24, at 12:10 p.m. revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
During an interview on 7/31/24, at 1:05 p.m. Social Worker Employee E1 stated I faxed all the information but did not document anything.
During an interview on 7/31/24, at 2:10 p.m. Director of Nursing confirmed that the facility failed to obtain a physician's order for a discharge and make certain that the necessary resident information was communicated to the receiving health care provider for one out of five residents sampled with facility-initiated transfers (Resident R1).
28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.
Jun 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
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents and staff and resident interview it was determined that the facility failed to resolve con...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents and staff and resident interview it was determined that the facility failed to resolve concerns for 2 of 2 resident's reviewed.
Findings include:
Review of Resident R2's admission record indicated she was originally admitted on [DATE], with diagnoses that included anxiety, osteoarthritis and difficulty walking.
Review of Resident R2's quarterly Minimum Data Set(MDS-a periodic assessment of care) dated 5?10/24 indicated diagnosis remain current. Interview for Mental Status (BIMS a screening test that aides in detecting cognitive function.
The BIMS total score suggests the following distributions:
13-15 cognitively intact
8-12 moderately impaired
0-7 severe impairment
Resident R1's score was 15- cognitively intact
Review of facility documentation indicated Resident R2's had a grievance on 5/31/24. She stated she did not get care. The facility resolution was to put a white board in Resident R2's room with who her nurse and nurse aide for the day.
Interview on 6/27/24 at 12:35 p.m. Resident R2 stated the concern above were not resolved. The white board was dated 6/25/24 and had no staff listed. Resident R2 stated why have the board, there is nothing on it.
Review of Resident R1's admission record indicated he was admitted on [DATE], with diagnoses that included neuromuscular dysfunction of bladder, major depressive disorder and muscle weakness.
Review of Resident R1's quarterly Minimum Data Set(MDS-a periodic assessment of care)dated 6/15/24 indicated diagnosis remain current. Interview for Mental Status (BIMS a screening test that aides in detecting
The BIMS total score suggests the following distributions:
13-15 cognitively intact
8-12 moderately impaired
0-7 severe impairment
Resident R1's score was 15- cognitively intact
Review of facility documentation indicated Resident R1 on 5/1/24 needed help eating and was told no and was asked NA to go to bed, was told she was unavailable. 5/19/24 submitted a concern that no one was in to change him during the night.
Interview on 6/27/24 at 1:15 p.m. Resident R1 stated the concerns above were not resolved. Resident R1 stated he doesn't get assistance to eat and proper incontinence care at night. Resident R1 stated If there is a hell, this place is it
During an interview on 6/27/24, at 1:45 p.m. the Nursing Home Administrator confirmed that the facility failed to resolve grievances for 2 of 2 Resident R1 & R2.
28 Pa. Code: 207.2(a) Administrator's responsibility.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility failed to follow a physician order for o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility failed to follow a physician order for one of seven residents (Resident R1).
Findings include:
Review of Resident R1's admission record indicated he was originally admitted on [DATE], with diagnoses that included neuromuscular dysfunction of bladder, major depressive disorder and muscle weakness.
Review of Resident R1's quarterly MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 6/15/24, indicated that the diagnoses were current upon review.
Review of Resident R1's physician order's dated 5/17/24 indicated to administer Ferrous Gluconate Oral Tablet 324 (38 Fe) MG (Ferrous Gluconate) give 324 mg by mouth one time a day for anemia.
Review of Resident R1's physician order's dated 5/17/24 indicated to administer Protonix Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium)give 1 tablet by mouth one time a day for GERD.
Review of Resident R1's physician order's dated 5/17/24 indicated to administer LiquaCel Oral Liquid (Amino Acids) give 30 ml by mouth three times a day for wound healing.
Review of Resident R1's MAR (medical administration record), the following was not administered:
Ferrous Gluconate 6/15/24, 6/18/24, 6/22/24
Protonix 6/6/24, 6/9/24, 6/17/24
LiquaCel 6/22/24, 6/25/24
Review of Resident R1's clinical nurse notes indicated medications need reordered or not on cart and resident R1 did not receive on 6/6/24, 6/9/24, 6/15/24, 6/17/24, 6/18/24, 6/22/24 and 6/25/24.
During an interview on 6/27/24, at 2:00 p.m. the Director of Nursing (DON) confirmed that Resident R1's above medications were not available and were not administered per physician's order.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
May 2024
29 deficiencies
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interviews, it was determined the facility failed to notify the physician of a change in condition for one of six residents. (Resident R30).
Findings include:
Review of facility policy Notification of Changes dated 2/1/24, indicated the facility will immediately inform the resident; consult with the resident's physician; and if known, notify the resident's legal representative or an interested family member when there is:
- An accident involving the resident which results in injury and has the potential for requiring physician intervention.
- A significant change in the resident ' s physical, mental, or psychosocial status
- A need to alter treatment significantly.
Review of facility policy Protocol When to Call Physician dated 2/1/24, indicated the physicians caring for residents in your facility was to respond in an appropriate and timely manner to changes in condition as determined by the nursing staff and to address any concerns voiced by staff, residents or family members.
Review of the clinical record indicated Resident R30 was admitted to the facility on [DATE].
Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnoses of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).
Review of Resident R30's progress note indicated on 4/23/24, at 8:43 p.m. that Resident R30 was noted on floor in room on the side of bed closest to window; Resident positioned faced down no injury noted at this time; range of motion tolerated per Residents toleration times four extremities. Reddend area noted on left wrist, Resident alert to self with confusion. Resident bed positioned at lowest position.
Review of Resident R30's progress note indicated on 4/23/24, at 9:05 p.m. that resident was on the floor next to bed. upon entering room resident was laying on the right side of bed on floor face down. resident was assessed for injuries and repositioned onto her back for easy transfer. no injuries noted at this time. resident had small red area to left wrist that resident stated, that's been there. Resident R30 is alert times one and continuing on hospice. Resident R30 stated she was not in any pain. no signs or symptoms of pain or discomfort. resident transferred back into bed assist times 3. pillows placed on both sides of resident to help keep her from rolling out of bed. vitals (blood pressure, pulse, respirations) within normal limits. Afebrile (no fever). Neuros initiated. Physician notified. supervisor called husband but no answer. message left. will continue to monitor.
Review of Resident R30's progress note indicated on 4/23/24, at 10:47 p.m. that resident had an increase of pain and agitation this shift, resident was crying out, when asked she stated that she was in pain, and wanted help, also that she couldn't see, hospice notified, this nurse spoke with on call, hospice stated she will call supervisor and come out to assess resident and call before she comes. Supervisor notified, will continue to monitor.
Review of Resident R30's progress notes on 4/23/24, at 10:47 p.m. failed to have an assessment documented by a registered nurse with residents change in condition.
Review of Resident R30's progress note on 4/23/24, at 10:47 p.m. failed to include documentation of notifying the physician of change in condition when resident reported having increased pain and being unable to see after a fall.
During an Interview on 5/1/24, at 10:15 a.m. the Director of Nursing (DON) confirmed the facility failed to notify the physician of a change in condition for one of six residents (Resident R30).
28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, staff interview, and facility submitted documents, it was determined...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, staff interview, and facility submitted documents, it was determined that the facility failed to provide services to create an environment free from neglect for one of four residents (Resident R99).
Findings include:
Review of facility policy Abuse: Protection From Abuse dated 2/1/24, indicated residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services, treatment of care, including but not limited to: nutrition, medication, therapies, and activities of daily living.
Review of the clinical record indicated Resident R99 was admitted to the facility on [DATE].
Review of Resident R99's Minimum Data Set assessment (MDS - a periodic assessment of care needs) dated 2/12/24, indicated diagnosis of high blood pressure, hyperglycemia (high blood sugar levels in the blood), and pain in left knee.
A review of facility submitted documents dated 3/12/24, indicated that on 3/12/24, Resident R99 submitted a complaint to the facility that he had been left sitting in a soiled brief from 8:30 a.m. to 1:30 p.m. Once a statement was obtained from the resident, the facility was able to determine that Nurse Aide (NA) Employee E3 was caring for the resident during the time of occurrence. NA Employee E3 was removed from resident care until a full investigation could be completed.
Review of investigation documents dated 3/12/23, indicated Resident R99's roommate provided the following statement, NA Employee E3 came into room around 8:30 a.m. to answer call light, only turning it off and leaving saying she would be back. Around 1:30 p.m. NA Employee E3 came back and changed him (Resident R99) and left the room. Resident R99 was cold and not dressed in his bed. At 2:30 p.m. the second shift person covered him up.
Review of investigation documents dated 3/13/24, indicated Resident R99 provided the following statement, I put my call bell on and she (NA Employee E3) came into my room at 8:30 a.m. and turned it off and stated, I'll be back. She never came back until 1:30 p.m. to change my brief. I sat in my poop 5 hours. She changed my brief and left me in my bed with only a brief on. I was cold and she never came back in after the 1:30 p.m. brief change. Another person answered my call light and covered me up. I feel I sat too long in my brief with poop in it.
Review of investigation documents dated 3/13/24, indicated NA Employee E3 stated that Resident R99 put his call bell on for assistance on 3/12/24, around 12:15 p.m. when lunch trays had arrived. Resident R99 requested to be changed as he had a bowel movement. NA Employee E3 did not recall Resident R99 putting on his call bell at any other time during that shift. NA Employee E3 recalled that she had checked in on Resident R99 a couple of times during her shift and he did not need assistance. The last time she checked on him was at 10:00 a.m. and his brief ws clean and dry. At 1:30 p.m. NA Employee E3 entered Resident R99's room with NA Employee E4 and changed Resident R99. He was soiled with a bowel movement and required a change of his gown and sheets. NA Employee E3 and NA Employee E4 entered another residents room and when they came out of that room there were multiple people in the hall and they were talking about the fact that Resident R99 was upset he didn ' t have a gown on or have a sheet. NA Employee E3 remembered that she had forgotten to take them back to Resident R99 after he had been changed.
During an interview on 5/3/24, at 12:12 p.m. the Assistant Director of Nursing (ADON) confirmed that the facility failed to provide services to create an environment free from neglect for one of four residents (Resident R99).
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
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to conduct an FBI background check on an employee prior to working on ...
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Based on review of facility policy, newly hired personnel records and staff interviews it was determined that the facility failed to conduct an FBI background check on an employee prior to working on the nursing unit for one out of five personnel records (Registered Nurse Employee E6) and failed to properly screen an employment by completing a State background check prior to hire for one out of five personnel records (Dietary Aide Employee E17).
Findings include:
The facility Abuse: Protection from Abuse policy dated 1/23/23 and 2/1/24, indicated that the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegation of potential or actual abuse and neglect. Our facility conducts employee background checks and will not knowingly employ any individual who has been convicted of abusing, neglecting, or mistreating individuals. Screening- protocols for conducting employment background checks; background checks include State Criminal and Federal Criminal (if applicable).
Review of Registered Nurse Employee E6's personnel record indicated she was hired on 1/23/24.
Review of Registered Nurse Employee E6's personnel record revealed resident has not lived in Pennsylvania for two consecutive years and indicated a home address that was out of the state.
Review of Registered Nurse Employee E6's personnel record did not reveal that a FBI background check and fingerprint check was completed prior to her start date of employment.
During an interview on 5/2/24, at 1:40 p.m. Human Resource Employee E18 stated, They do not show me proof that they did the FBI background check prior to their date of hire, we just get the results sent to us.
During an interview on 5/2/24, at 2:05 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct an FBI background check on Registered Nurse Employee E6 prior to her working on the nursing unit as required.
Review of Dietary Aide Employee E17's personnel record indicated she was hired 2/16/24.
Review of Dietary Aide Employee E17's personnel record did not include a state criminal background check prior to her date of hire.
During an interview on 5/2/24, at 1:32 p.m. Human Resource Employee E18 stated, I was off on medical leave and when I came back, I noticed it wasn ' t completed so I did it.
During an interview on 5/2/24, at 2:05 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to properly screen Dietary Aide Employee E17 by completing a state criminal background check prior to hire as required.
28 Pa Code: 201.14(a) (c)(d)(e) Responsibility of licensee
28 Pa Code 201.18(b)(1)(2)(e)(1) Management.
28 Pa Code: 201.19 Personnel policies and procedures
28 Pa Code: 201.20 (a)(b)(c)(d) Staff development
28 Pa Code: 201.29 (d) Resident Rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical record, reports submitted to the State, and staff interview it was determi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical record, reports submitted to the State, and staff interview it was determined that the facility failed to report two allegations of abuse for one of three sampled residents (Resident R67).
Findings include:
The facility Abuse:Protection from Abuse policy dated 1/23/23 and 2/1/24, indicated that the resident have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse or neglect.
The facility Abuse Reporting and Investigation policy dated 1/23/23 and 2/1/24, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse (mental, physical, sexual, involuntary seclusion or misappropriation of resident property), neglect or exploitation. The Department of Health will be notified of the alleged event via Electronic Reporting System (ERS) per regulation. Provider Bulletin 22 (PB22) will be completed and forwarded to the Department of Health within 5 working days of the incident.
Review of Resident R67's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R67's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/3/24, indicated diagnosis of osteoarthritis (degeneration of the joint causing pain and stiffness), depression, and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
During an interview on 4/29/24, at 1:40 p.m. Resident R67 stated that she had arranged with a certified nurse aide that she will get ready for bed around ten o'clock p.m. per her choice this past Friday or Sunday.
During an interview on 4/29/24, at 1:45 p.m. Resident R67 stated, I'm afraid of retaliation but I'll tell you. This weekend, Friday or Sunday an aide told me that I would either have to get cleaned up now or you will have to stay wet. The aide allegedly told Resident R67, [NAME] ' t tell us how to do our job. Resident R67 stated, It's scary. Resident stated that she was not ready for care to be provided at this time.
During an interview on 4/29/24, at 2:21 p.m. the Nursing Home Administrator (NHA) and Director of Nursing was made aware of allegation from 4/29/24.
Review of Resident R67 clinical record on 4/30/24, at 1:07 p.m. indicated that on 10/2/23, resident was upset and shaken. Resident was insulted by staff member calling her fat because her legs rub and she doesn't move. Staff member told her that she can roll over independently, but she is just too lazy too.
During an interview on 4/30/24, at 1:12 p.m. the Director of Nursing was made aware of allegation from 10/2/23.
During an interview on 5/3/24, at 12:00 p.m. the facility failed to provide evidence to indicate the abuse allegations from 4/29/24 and 4/30/24 were reported to the local State field office.
During an interview on 5/3/24, at 2:13 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to report two allegations of abuse for one of three sampled residents (Resident R67).
28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management
28 Pa Code: 201.18 (b)(1) (e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, reports submitted to the state, and staff interviews, it was determined th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, reports submitted to the state, and staff interviews, it was determined that the facility failed to conduct a thorough investigation to rule out abuse for one of three residents (Resident R67).
Findings include:
The facility Abuse: Protection from Abuse policy dated 1/23/23 and 2/1/24, indicated that the resident have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect, and misappropriation of property. The facility shall have processes in place to include screening, training, prevention, identification, protection, investigation, reporting and response to allegations of potential or actual abuse or neglect.
The facility Abuse Reporting and Investigation policy dated 1/23/23 and 2/1/24, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse (mental, physical, sexual, involuntary seclusion or misappropriation of resident property), neglect or exploitation. The Department of Health will be notified of the alleged event via Electronic Event Reporting System (ERS) per regulation. Provider Bulletin 22 (PB22) will be completed and forwarded to the Department of Health within 5 working days of the incident.
Review of Resident R67's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R67's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/3/24, indicated diagnosis of osteoarthritis (degeneration of the joint causing pain and stiffness), depression, and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
During an interview on 4/29/24, at 1:40 p.m. Resident R67 stated that she had arranged with a certified nurse aide that she will get ready for bed around ten o'clock p.m. per her choice this past Friday or Sunday.
During an interview on 4/29/24, at 1:45 p.m. Resident R67 stated, I'm afraid of retaliation but I'll tell you. This weekend, Friday or Sunday an aide told me that I would either have to get cleaned up now or you will have to stay wet. The aide allegedly told Resident R67, [NAME] ' t tell us how to do our job. Resident R67 stated, It's scary. Resident stated that she was not ready for care to be provided at this time.
During an interview on 4/29/24, at 2:21 p.m the Administrator and Director of Nursing was made aware of allegation from 4/29/24.
Review of Resident R67 clinical record on 4/30/24, at 1:07 p.m. indicated that on 10/2/23, resident was upset and shaken. Resident was insulted by staff member calling her fat because her legs rub and she doesn't move. Staff member told her that she can roll over independently, but she is just too lazy too.
During an interview on 4/30/24, at 1:12 p.m. the Director of Nursing was made aware of allegation from 10/2/23.
During an interview on 5/3/24, at 12:00 p.m. the Director of Nursing failed to provide investigations for reported abuse allegations from 4/29/24 and 4/30/24.
During an interview on 5/3/24, at 2:13 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to conduct a thorough investigation to rule out abuse for one of three residents (Resident R67) as required.
28 Pa. Code 201.14(a)(c)(e) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, clinical records, and staff interviews, it was determined that the facility failed to not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documents, clinical records, and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for one of seven resident hospital transfers (Resident R57).
Findings Include:
Review of the admission Packet which is provided to residents upon admission, it was indicated that before the facility transfers a resident to the hospital or the resident goes on therapeutic leave, the facility shall provide written notice to Resident or Resident Representative.
Review of the clinical record indicated Resident R57 was admitted to the facility on [DATE].
Review of Resident R57's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/8/24, indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension (high blood pressure in the arteries) and stroke (an event that occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts).
Review of Resident R57's clinical record revealed that the resident was transferred to the hospital on 1/6/24.
Review of Resident R57's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital on 1/6/24.
During an interview on 5/2/24, at 9:22 a.m. Director of Nursing confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for Resident R57's hospital transfer.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, resident observation, and staff interviews, it was determined that the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review, resident observation, and staff interviews, it was determined that the facility failed to follow physician's orders for one of two residents (Resident R311).
Findings include:
Review of facility policy, Medication and Treatment Orders, dated 2/1/24 indicate each medication administered will have a corresponding and complete physician ' s order.
Review of facility policy, Treatment and services, dated 2/1/24 indicate based on the comprehensive assessment of a resident, the facility must ensure that a resident is given the appropriate treatment and services to maintain or improve his or her abilities.
Review of Resident R311's clinical record indicated he was admitted to the facility on [DATE].
Review of Resident R311's Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/24/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension (high blood pressure in the arteries) and osteomyelitis (inflammation of bone caused by infection).
Review of Resident R311's active physician order dated 4/19/23, indicated change PICC (a type of long catheter that is inserted through a peripheral vein, often in the arm, into a larger vein in the body used when intravenous treatment is required over a long time) line dressing every day shift, every seven days for catheter care.
Review of Resident R311's care plan, dated 4/23/24 indicated dressing change per physician order.
During an observation on 5/1/24, at 10:57 a.m. Resident R311's PICC line dressing was dated 4/23/24.
Review of Resident R311's clinical record on 5/1/24, at 12:20 p.m. failed to provide documentation from a licensed nurse that the treatment was completed and signed on the Treatment Administration Record (TAR) on 4/30/24.
During an interview on 5/1/24, at 12:38 p.m. Licensed Practical Nurse (LPN) Employee E8, confirmed the PICC line dressing was dated 4/23/24 on Resident R311's arm.
During an interview on 5/1/24, 12:47 p.m. Director of Nursing confirmed the facility failed to follow physician ' s orders for one of two residents (Resident R311).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(a)(b)(3) Management.
28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical records and staff interview it was determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical records and staff interview it was determined that the facility failed to obtain laboratory results and promptly report those results as per order for one out of two sampled residents (Resident R17).
Findings include:
The facility Laboratory services policy dated 8/2016, and last reviewed 2/1/24, indicated that laboratory studies will be obtained only when ordered by a physician. The facility will notify the physician of the results promptly and laboratory findings will be filed in the resident record. The facility will have a system to reconcile physician orders, lab orders, and results received.
Review of Resident R17's admission record indicated she was admitted on [DATE].
Review of Resident R17's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 4/10/24, indicated she had diagnoses that included major depressive disorder (a state of consistent sadness and loss of interest interfering in daily life activities), hypertension (a condition impacting blood circulation through the heart related to poor pressure), and hematuria (blood in urine).
Review of Resident R17's care plans dated 4/16/24, indicated to obtain and monitor laboratory results as ordered and report results to a physician.
Review of Resident R17's physician orders dated 4/27/24, indicated to obtain a complete blood count (CBC) one time for infection prevention.
Review of Resident R17's physician orders dated 4/27/24, indicated to obtain an urinalysis (a urine test) one time for urinary tract infection.
Review of Resident R17's CBC lab results dated 4/27/24, indicated a high white blood cell count of 10.40.
Review of Resident R17's physician orders dated 4/27/24, indicated to administer Macrobid (antibiotic) 100mg twice a day by mouth for seven days. Resident R 17 diagnosis was a urinary tract infection.
Review of Resident R17's urinalysis results dated 4/29/24, indicated that superficial bacteria does not show a urinary tract infection.
Review of Resident R17's physician notes and clinical nurse notes did not indicate a notification to the doctor about the results of the 4/29/24 urinalysis showing Resident R17 did not have an active urinary tract infection.
Review of Resident R17's April 2024 and May 2024 Medication Administration Record (MAR) indicated that she received Macrobid 100mg on 4/28/24, 4/29/24, 4/30/24, 5/1/24, and 5/2/24.
During an interview on 5/2/24, at 12:19 p.m. Registered Nurse (RN) Employee E6 confirmed that the facility failed to obtain laboratory results and promptly report those results as per order for Resident R17 as required.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
Based on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of four observed meals (lunch meal 4/30/...
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Based on observations, facility menu, resident interviews, and staff interviews it was determined that the facility failed to follow the displayed menu for one of four observed meals (lunch meal 4/30/24).
Findings include:
During an interview on 4/29/24, at 12:19 p.m. Resident R59 stated that she often does not receive food items that are on her meal ticket or menu.
Review of lunch menu for 4/30/24 revealed that the vegetable was to be broccoli cuts, and that the alternative vegetables were peas, green beans, and carrots.
During an observation in the Main Dining Room on 4/30/24, at 12:46 a.m., no residents were served broccoli, but had Winter Blend vegetables (cauliflower, carrots and broccoli) instead.
Review of Resident R9, R17, R21, R58, and R210's meal tickets all indicated that they were to have received broccoli cuts, but received Winter Blend instead.
During an interview on 4/30/24, at 1:00 p.m. Food Service Director (FSD) Employee E9 stated that he was aware that broccoli was on the menu but that he did not receive it in the food delivery so he served the Winter Blend instead. When FSD Employee E9 was asked if he had approval from the Registered Dietitian to change the menu or alert residents of the change in the menu, he replied no.
During an interview on 4/30/24, at 1:01 p.m., FSD Employee E9 confirmed that facility failed to properly display and update the menu being served for the lunch meal on 4/30/24.
Pa Code: 211.6(a) Dietary 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 F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, observation, resident interview, and staff interview, it was determined that the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, observation, resident interview, and staff interview, it was determined that the facility failed to serve food products that appeared palatable for one of four meals observed (lunch meal on 4/29/24).
Findings include:
Review of facility policy Meal Service Line, dated 2/1/24, indicated that the facility will serve food that will be prepared by methods that conserve nutritive value, flavor, and appearance, and will be placed on trays in an attractive manner.
During an observation on 4/29/24, at 12:19 p.m. Resident R59 had her lunch tray in front of her, but was not eating.
During an observation on 4/29/24, at 12:19 p.m., Resident R59's meal ticket stated that she was to have received fried chicken, however, there was no fried chicken on her tray and there was a very dry, hard, and stringy appearing piece of meat.
During an interview on 4/29/24, at 12:20 p.m. Resident R59 was asked what her entrée was and she replied, I think it's left over roast beef from yesterday.
During an interview in Resident R59's room on 4/29/24, at 12:47 p.m. Food Service Director (FSD) Employee E9 confirmed that Resident R59 was served leftovers from yesterday's lunch of [NAME] pot roast, and confirmed that the meat appeared to be very dry and unappetizing. FSD confirmed that the facility failed to provide food products that appeared palatable for the lunch meal on 4/29/24.
Pa Code 211.6(b)(c)(d) Dietary Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected 1 resident
Based on facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of one outside dumpsters to prevent the potentia...
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Based on facility policy, observation, and staff interview it was determined that the facility failed to properly contain and dispose of garbage in one of one outside dumpsters to prevent the potential for rodent and insect infestation.
Findings include:
Review of facility policy Garbage and Rubbish Disposal Policy, date 2/1/24, indicated that outside dumpsters provided by the garbage pick-up services must be kept closed and free of litter around the dumpster area.
During an observation of the facility's outdoor trash receptacle on 4/29/23, at 9:32 a.m. revealed the lids/covers were not closed on the dumpster.
During an interview on 4/29/24, at 9:32 a.m. Food Service Director Employee E9 confirmed that the facility failed to properly contain and dispose of garbage in the outside trash receptacles to prevent the potential for rodent and insect infestation.
28 Pa. Code 201.18(b)(3) Management.
28 Pa. Code 207.2(a) Administrator's responsibility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to maintain and complete accurat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to maintain and complete accurate documentation for two of nine residents (Resident R3 and R12).
Findings include:
Review of facility policy Documentation dated 2/1/24, indicated nursing documentation will provide accurate reflection of a resident condition that will meet federal and state requirements.
Review of Title 42 Code of Federal Regulations (CFR) §483.709(i) Medical records. In accordance with accepted professional standards and practice, the facility must maintain medical records that are complete, accurately documented, readily accessible, and systematically organized.
Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].
Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/11/24, indicated active diagnosis of high blood pressure, dementia, and muscle weakness.
Review of a physician order dated 1/2/24, indicated to weigh patient every day shift every month starting on the 2nd day of the month.
Review of a physician order dated 1/18/24, indicated to weigh resident every day shift every Thursday. This order was discontinued on 2/11/24.
Review of Resident R3's clinical record failed to reveal that a weight was documented in the electronic medical record on 1/25/24, 2/1/24, 2/8/24, 3/2/24, and 4/2/24.
During an interview on 5/3/24, at 12:09 p.m. the Assistant Director of Nursing (ADON) provided facility documentation to indicate that Resident R3's ordered weights were documented on paper sheets dated 1/2/24, 2/2/24, 2/9/24, 3/2/24, and 4/2/24. During this interview the ADON confirmed that these weights had not be transferred to the electronic medical record and were not readily accessible for review.
Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE].
Review of Resident R12's Minimum Data Set MDS dated [DATE], indicated diagnosis of high blood pressure, muscle weakness, and dependence on supplemental oxygen.
Review of a physician order dated 12/18/24, indicated to weigh resident every day shift every Thursday. This order was discontinued on 2/23/24.
Review of Resident R12's clinical record failed to reveal that a weight was documented in the electronic medical record on 2/1/24, 2/8/24, and 2/15/24. Further review of R12's clinical record failed to reveal a weight documented in the electronic medical record for February and March 2024.
During an interview on 5/3/24, at 12:09 p.m. the ADON provided facility documentation to indicate that Resident R12's ordered weights were documented on paper sheets dated 2/2/24, 2/9/24, 2/16/24, and 3/2/24. During this interview the ADON confirmed that these weights had not be transferred to the electronic medical record and were not readily accessible for review.
During an interview on 5/3/24, at 10:39 a.m. Registered Dietitian (RD) Employee E10 stated, I come in to the facility once a week, usually on Thursdays. I do a lot of my charting remotely from home. I rely on weights being documented in the electronic medical record for my charting.
During an interview on 5/3/24, at 12:09 p.m. the ADON confirmed that the facility failed to maintain and complete accurate documentation for two of nine residents (Resident R3 and R12).
28 Pa. Code 211.5(f) Clinical Records.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, resident clinical records, and staff interviews, it was determined the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, resident clinical records, and staff interviews, it was determined the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of four residents (Resident R30).
Findings include:
Review of the facility's Hospice Care Policy dated, 2/1/24, indicated hospice care will be offered to residents, as ordered by the attending physician, to provide additional supportive care for residents with end-stage terminal illnesses. Social services or designee will obtain a physician ' s order and contact Hospice Agency. All hospice services are provided under contractual arrangements.
Review of Resident R30's clinical record indicated the resident was admitted to the facility on [DATE].
Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnoses of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).
Review of Resident R30's documentation from the resident's hospice provider dated 3/13/24, indicated the resident was admitted to their services on 3/13/24.
Review of Resident R30's care plan initiated 5/1/24, indicated the resident is receiving hospice care related to end stage illness.
Review of Resident R30's clinical record failed to include a completed hospice contract between the facility and hospice provider.
Review of Resident R30's physician orders dated 4/27/24, included a hospice phone number for hospice services.
Review of Resident R30's physician orders dated 3/13/24 through 5/1/24 failed to include a physician order for hospice services.
During an interview on 5/1/24, at 10:40 a.m. Director of Nursing stated, I don ' t see an order but I will get one put in.
During an observation on 5/1/24, at 12:30 p.m. Nursing Home Administrator provided a contract which failed to identify resident name, what kind of contract and which hospice provider was contracted to provide services to Resident R30.
During an interview on 5/1/24, at 10:42 a.m. Director of Nursing confirmed the facility failed to obtain a physician order for hospice services and to ensure the coordination of hospice services with facility services to meet the needs of each resident for end of life care for one of four residents (Resident R30).
28 Pa. Code 211.2(a) Physician services
28 Pa. Code 211.11(d) Resident care plan
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to provide documentation of advanced directives or given the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of eight residents reviewed (Resident R8, R30, R50, R67, R75, R86, R87, and R311).
Findings include:
A review of the facility policy Advanced Directives last reviewed [DATE], indicated that the facility has policies and procedures which allow the withholding of CPR (Cardiopulmonary Resuscitation - emergency life-saving procedure that is done when breathing or a heartbeat has stopped) measures from individual residents who have an Advanced Directives stating they do not want to be resuscitated. The procedures for determining when the services may be withheld must respect the resident ' s rights of self-determination. This nursing home will inform the resident of the policies and procedures upon admission or at such times as may be appropriate.
Review of Resident R8's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R8's MDS (Minimum Data Set, periodic assessment of resident care needs) dated [DATE], indicated diagnosis of hypertension (high blood pressure in the arteries), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression.
A review of the clinical record failed to reveal an advanced directive or documentation that Resident R8 was given the opportunity to formulate an Advanced Directive.
Review of Resident R30's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R30's MDS dated [DATE], indicated diagnosis of hypertension, multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures.
A review of the clinical record failed to reveal an advanced directive or documentation that Resident R30 was given the opportunity to formulate an Advanced Directive.
Review of Resident R50's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R50's MDS dated [DATE], indicated diagnosis of hypertension, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat).
A review of the clinical record failed to reveal an advanced directive or documentation that Resident R50 was given the opportunity to formulate an Advanced Directive.
Review of Resident R67's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R67's MDS dated [DATE], indicated diagnosis of osteoarthritis (degeneration of the joint causing pain and stiffness), depression, and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
A review of the clinical record failed to reveal an advanced directive or documentation that Resident R67 was given the opportunity to formulate an Advanced Directive.
Review of Resident R75's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R75's MDS dated [DATE], indicated diagnosis of hypertension, dementia, and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).
A review of the clinical record failed to reveal an advanced directive or documentation that Resident R75 was given the opportunity to formulate an Advanced Directive.
Review of Resident R86's clinical record indicated he was admitted to the facility on [DATE].
Review of Resident R86's MDS dated [DATE], indicated diagnosis of hypertension, malnutrition (lack of nutrients to the body), and dysphagia (difficulty swallowing).
A review of the clinical record failed to reveal an advanced directive or documentation that Resident R86 was given the opportunity to formulate an Advanced Directive.
Review of Resident R87's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R87's MDS dated [DATE], indicated diagnosis of depression, diabetes, and heart failure.
A review of the clinical record failed to reveal an advanced directive or documentation that Resident R87 was given the opportunity to formulate an Advanced Directive.
Review of Resident R311's clinical record indicated he was admitted to the facility on [DATE].
Review of Resident R311's MDS dated [DATE], indicated diagnosis of diabetes, hypertension, and osteomyelitis (inflammation of bone caused by infection).
A review of the clinical record failed to reveal an advanced directive or documentation that Resident R311 was given the opportunity to formulate an Advanced Directive.
During an interview on [DATE], at 9:17 a.m. Social Worker Employee E19 confirmed that advanced directives are not part of the documentation in the clinical record.
During an interview on [DATE], at 9:20 a.m. the Director of Nursing confirmed that the facility failed to provide documentation of advanced directives or given the opportunity to formulate an advance directive for eight of eight residents reviewed (Resident R8, R30, R50, R67, R75, R86, R87, and R311).
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for five out of seven residents sampled with facility-initiated transfers (Residents R30, R57, R59 R75, and R87).
The findings include:
Review of Resident R30's clinical record indicated the resident was admitted to the facility on [DATE].
Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnoses of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).
Review of Resident 30's clinical record revealed that the resident was transferred to the hospital on 4/27/24 and returned to the facility on 4/27/24, same day.
Review of Resident R30's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
Review of the clinical record indicated Resident R57 was admitted to the facility on [DATE].
Review of Resident R57's MDS dated [DATE], indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension, and stroke (an event that occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts).
Review of Resident R57's clinical record revealed that the resident was transferred to the hospital on 1/6/24, and returned on 1/8/24
Review of Resident R57's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
Review of clinical record indicated that Resident R59 was admitted to the facility on [DATE].
Review of Resident 59's MDS dated [DATE], indicated diagnoses of diabetes, high blood pressure, and dysphagia (difficulty swallowing).
Review of Resident 59's clinical record revealed that the resident was transferred to the hospital on [DATE], and returned on 12/24/23.
Review of Resident R59's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
Review of the clinical record indicated Resident R75 was admitted to the facility on [DATE].
Review of Resident R75's MDS dated [DATE], indicated diagnoses hypertension, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).
Review of Resident R75's clinical record revealed that the resident was transferred to the hospital on 3/9/24 returned to the facility on 3/14/24.
Review of Resident R75's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
Review of the clinical record indicated Resident R87 was admitted to the facility on [DATE].
Review of Resident R87's MDS dated [DATE], indicated diagnoses of depression, and, heart failure (a progressive heart disease that affects pumping action of the heart muscles).
Review of Resident R87's clinical record revealed that the resident was transferred to the hospital on [DATE] returned to the facility on [DATE].
Review of Resident R87's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
During an interview on 5/1/24, at 9:36 a.m. the Director of Nursing (DON) stated, they send information in a packet, but they don't specifically document what they send.
During an interview on 5/1/24, at 2:03 p.m. the Director of Nursing confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider upon transfer for five out of five residents sampled with facility-initiated transfers (Residents R30, R57, R59, R75, and R87).
28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to not...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident/resident representative and/or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers, in writing, to include to include the following: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, and name, address (mailing and email), and telephone number of the Office of the State Long-Term Care Ombudsman for five of seven resident records reviewed (Resident R30, R57, R59, R75, and R87)
Findings Include:
Review of Title 42 Code of Federal Regulations §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged ;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.
Review of Resident R30's clinical record indicated the resident was admitted to the facility on [DATE].
Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnoses of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures).
Review of Resident 30's clinical record revealed that the resident was transferred to the hospital on 4/27/24 and returned to the facility on 4/27/24, same day.
Review of Resident R30's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the resident/resident representative and or Office of Long-Term Care Ombudsman for the hospitalization on 4/27/24.
Review of the clinical record indicated Resident R57 was admitted to the facility on [DATE].
Review of Resident R57's MDS dated [DATE], indicated diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension, and stroke (an event that occurs when something blocks blood supply to part of the brain or when a blood vessel in the brain bursts).
Review of Resident 57's clinical record revealed that the resident was transferred to the hospital on 1/6/24, and returned on 1/8/24.
Review of Resident R57's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the resident/resident representative and or Office of Long-Term Care Ombudsman for the hospitalization on 1/8/24
Review of clinical record indicated that Resident R59 was admitted to the facility on [DATE].
Review of Resident 59's MDS dated [DATE], indicated diagnoses of diabetes, high blood pressure, and dysphagia (difficulty swallowing).
Review of Resident 59's clinical record revealed that the resident was transferred to the hospital on [DATE], and returned on 12/24/23.
Review of Resident R59's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the resident/resident representative and or Office of Long-Term Care Ombudsman for the hospitalization on 12/22/23.
Review of the clinical record indicated Resident R75 was admitted to the facility on [DATE].
Review of Resident R75's MDS dated [DATE], indicated diagnoses hypertension, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).
Review of Resident R75's clinical record revealed that the resident was transferred to the hospital on 3/9/24 returned to the facility on 3/14/24.
Review of Resident R75's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the resident/resident representative and or Office of Long-Term Care Ombudsman for the hospitalization on 3/9/24.
Review of the clinical record indicated Resident R87 was admitted to the facility on [DATE].
Review of Resident R87's MDS dated [DATE], indicated diagnoses of depression, diabetes, and heart failure (a progressive heart disease that affects pumping action of the heart muscles).
Review of Resident R87's clinical record revealed that the resident was transferred to the hospital on [DATE] returned to the facility on [DATE].
Review of Resident R87's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the resident/resident representative and or Office of Long-Term Care Ombudsman for the hospitalization on 3/9/24.
During an interview on 5/2/24, at 9:22 a.m. Director of Nursing confirmed that the facility failed to notify the resident/resident representative and or the representative of the Office of the State Long-Term Care Ombudsman of resident transfers in writing for five of seven residents (Resident R30, R57, R59, R75, and R87).
28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for three of six sampled residents (Resident R3, R21, and R37).
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 October 2023, indicated indicated the following instructions: Section K - Swallowing/Nutritional Status: base weight on the most recent measure in the last 30 days. If the last recorded weight was taken more than 30 days prior to the Assessment Reference Date (ARD) of this assessment or previous weight is not available, weigh the resident again. Section O-Hospice care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider.
The facility Resident assessment minimum data set policy dated 2/1/24, indicated that the facility will conduct initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity under the direction of a designated registered nurse. The assessment will accurately reflect the resident's status assuring that each resident receives an accurate assessment by staff that are qualified to assess relevant care areas.
Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].
Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/11/24, indicated active diagnosis of high blood pressure, dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), and muscle weakness. Review of Section K: Swallowing/Nutritional Status, Question K0200 Height and Weight indicated Resident R3's documented weight was 193 pounds. Review of the clinical record indicated Resident R3's last documented weight was 193 pounds on 2/2/24.
During an interview on 5/2/24, at 1:10 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed that Resident R3's weight from 2/2/4, was used to complete her MDS dated [DATE], due to a more recent weight not being documented in the medical record.
Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE].
Review of Resident R21's MDS dated [DATE], indicated diagnoses of cancer, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and chronic pain. Section K0200 Weight indicated Resident R21's weight was 115 pounds. Review of Resident R21's clinical record indicated Resident R21's last docuemnted weight was 115 pounds on 2/1/24
During an interview on 5/2/24, at 12:59 p.m. LPNAC Employee E2 confirmed that the facility failed to weigh Resident R21 monthly and to ensure that MDS assessments accurately reflect Resident R21's weight status.
Review of Resident R37's admission record indicated she was originally admitted on [DATE].
Review of Resident R37's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 3/1/24, indicated she had diagnoses that included schizoaffective disorder (a mental disorder in which a person experiences a combination of schizophrenia and mood disorder symptoms), dementia (loss of cognitive function, thinking, remembering, and reasoning), anxiety disorder (a medical condition creating a sense of acute fear, restlessness, and worry), and hypothyroidism (decrease in production of thyroid hormone). The assessment indicated that these diagnoses were the most recent upon review.
Review of Resident R37's care plans dated 12/11/23, indicated that Resident R37 was on hospice.
Review of Resident R37's physician order dated 12/5/23, indicated to admit to hospice.
Review of Resident R37's clinical nurse notes dated 2/1/24, 3/25/24, and 4/22/24, indicated that she was receiving hospice services.
Review of Resident R37's MDS assessment dated [DATE], Section O-Hospice care was left blank, indicating she was not receiving hospice services during the look back period.
During an interview on 5/1/24, at 10:48 a.m. the Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed that the facility failed to ensure that MDS assessments accurately reflected the resident's status for Resident R37 as required.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
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 facility policies and job descriptions, clinical records, and staff interviews, it was determined that the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and job descriptions, clinical records, and staff interviews, it was determined that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings for 12 of 12 months, and completion of Nutrition Assessments by the Registered Dietitian for two of eight residents reviewed (Residents R21 and R59).
Findings include:
The Pennsylvania Code, Title 49, Chapter 21, Professional and Vocational Standards: Responsibilities of the Licensed Dietitian/ Nutritionist Section 21.711 Professional Conduct indicated that the Licensed Dietitian/ Nutritionist shall provide information which will enable patients to make their own informed decisions regarding nutrition and dietetic therapy, including the reasonable expectations of the professional relationship.
Review of facility policy Resident Weights, dated 2/1/24, indicated that the facility will identify residents at risk for significant weight change and ensure uniform tracking and reporting of resident weights. Monthly weights will be obtained weekly times four weeks following admission/readmission and monthly thereafter. The licensed nurse will notify the Interdisciplinary Team for further assessment.
Significant weight loss is defined as:
5% or greater in one month
7.5% or greater in three months
10% or greater in six months.
Review of Registered Dietitian's Job Description revealed that the purpose of Registered Dietitian's job position is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing and directing the food and nutritional services of the facility. Registered Dietitian must interpret and evaluate information on a patient's chart and make recommendations for appropriate medical nutrition therapy.
Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE].
Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/24, indicated diagnoses of cancer, dementia (a group of symptoms that affects memory , thinking and interferes with daily life), and chronic pain.
Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21 was weighed on 2/1/24 at 115 pounds which reflected a significant weight loss of 10.2% in six months, and that Resident R21 had not been weighed since the 2/1/24/ weight was obtained.
Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21's February weight loss was not addressed in February by the Registered Dietitian (RD) Employee E10.
Review of clinical record indicated that Resident R59 was admitted to the facility on [DATE].
Review of Resident 59's MDS dated [DATE], indicated diagnoses of diabetes (high sugar level in the blood), high blood pressure, and dysphagia (difficulty swallowing). Section K0520:- Nutritional Approaches, Therapeutic diet was checked, indicating that While a Resident in the past seven days, this nutritional approach was performed.
Review of Resident R59's clinical record failed to reveal nutritional assessment documentation addressing her nutritional status and therapeutic diet captured by MDS dated [DATE].
During an interview on 5/2/24, at 12:59 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed that the facility failed to timely assess Resident R21's significant weight loss, and failed to timely assess the nutritional status of Resident R59.
During a telephone interview on 5/3/24, at 10:39 a.m. RD Employee E10 stated that she began working at the facility one year ago when the census was 70 residents, but that the census has been climbing over the past several months and is now 104. RD Employee E10 confirmed that she is the only employee who performs clinical nutrition evaluations, and addresses weight loss at the facility. RD Employee E10 also stated that she comes into the facility one day per week, as she has a full time job in another facility and works part-time in a third facility. RD Employee E10 confirmed that not all nutritional evaluations are completed as required in a timely manner. RD Employee E10 also stated that since she is only in the facility one time per week, she does not participate in residents' care conferences or interdisciplinary team meetings. RD Employee E10 also confirmed that she does not always perform admission evaluations in person but that she has completed them remotely without having spoken to the residents.
During an interview on 5/3/24, at 11:41 a.m. Nursing Home Administrator confirmed that the facility failed to adhere to acceptable standards of practice related to participation in interdisciplinary meetings for 12 of 12 months, and completion of Nutrition Assessments by the Registered Dietitian for two of eight residents reviewed (Residents R21, and R59).
28 Pa. Code: 201.14(a) Responsibility of Licensee.
28 Pa. Code: 211.12(d)(1) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, a resident council group interview, resident and staff interviews, i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, a resident council group interview, resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided and failed to provide adequate hygienic care for eight out of 12 sampled residents (Resident R30, R50, R63, R67 R75, R87, R311, and R312 ).
Findings include:
The facility Flow of care policy dated 2/1/24, indicated that residents are to have two baths or showers per week unless the resident states otherwise.
Review of Resident R30's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnosis of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures.
Review of Resident R30's care plans dated 8/24/20, indicated to monitor skin during baths and showers as scheduled.
Review of Resident R30's shower documentation dated April 2024, indicated no showers were provided for April 2024.
Review of Resident R50's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R50's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/7/24, indicated diagnosis of hypertension (high blood pressure in the arteries), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat).
Review of Resident R50's shower documentation dated April 2024, indicated only two showers in April 2024 (4/9/24 and 4/23/24).
During an observation, on 4/30/24, at 1:42 p.m. Resident R50 was sitting in wheelchair with facial hair on her chin.
Review of Resident R63's admission record indicated she was admitted on [DATE].
Review of Resident R63's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 2/9/24, indicated she had diagnoses that included hyperlipidemia (elevated lipid levels within the blood), hypothyroidism (decrease in production of thyroid hormone), and chronic kidney disease (a loss of kidney function resulting in the swelling of feet, fatigue, high blood pressure and changes in urination).
Review of Resident R63's care plans dated 1/17/24, indicated to monitor skin during showers and baths.
Review of Resident R63's shower documentation dated April 2024, indicated only two showers in April 2024 (4/1/24 and 4/5/24).
During a resident interview on 4/29/24, at 10:18 a.m. Resident R63 stated the following: i am only getting showers once a week.
Review of Resident R67's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R67's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 2/3/24, indicated diagnosis of osteoarthritis (degeneration of the joint causing pain and stiffness), depression, and peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
Review of Resident R67's care plans dated 2/15/24, indicated provide a sponge bath when a full bath or shower cannot be tolerated.
Review of Resident R67's shower documentation dated April 2024, indicated no showers were provided for April 2024.
Review of Resident R67's clinical record on 5/1/24, the facility failed to provide documentation that the resident could not tolerate a shower for April 2024.
Review of Resident R75's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R75's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/21/24, indicated diagnosis of hypertension, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and cerebral infarction (necrotic tissue in the brain resulting loss of blood and oxygen to the brain).
Review or Resident R75's care plans dated 4/28/24, indicated to provide a sponge bath when a full bath or shower can not be tolerated.
Review of Resident R75's shower documentation dated April 2024, indicated no showers were provided for April 2024.
Review of Resident R75's clinical record on 5/1/24, the facility failed to provide documentation that the resident could not tolerated a shower for April 2024.
During an observation, on 4/29/24, at 11:19 a.m. Resident R75 was sitting at the side of bed with facial hair on her chin.
During an interview on 5/1/24, at 9:33 a.m. Resident R75 stated she would like her facial hair trimmed and does not like it.
Review of Resident R87's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R87's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/1/24, indicated diagnosis of depression, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and heart failure (a progressive heart disease that affects pumping action of the heart muscles).
Review of Resident R87's care plans dated, 10/11/23 That nails should always be cut straight across, never cut corners. File rough edges with emery board.
Review of Resident R 87's shower documentation dated April 2024, indicated no shower were provided for April 2024.
During an observation, on 4/29/24, at 1:04 p.m. Resident R87 was laying in bed with facial hair on her chin, her fingernails were long with discoloration and her hair was unkempt.
During an interview on 5/1/24, at 10:03 a.m. Resident R87 stated the following, I haven't gotten a shower for a while, I haven't gotten my hair washed and look at these fingernails, they are so long.
During an interview on 5/1/24, at 10:05 a.m. Resident R87 stated she would love to get her facial hair trimmed.
Review of Resident R311's clinical record indicated he was admitted to the facility on [DATE].
Review of Resident R311's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/24/24, indicated diagnosis of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), hypertension, and osteomyelitis (inflammation of bone caused by infection).
Review or Resident R311's care plans dated 4/23/24, indicated to monitor skin during baths and showers as scheduled.
Review of Resident R311's shower documentation dated April 2014, indicated no showers have been provided since date of admission on [DATE].
During an interview on 4/29/24, at 11:30 a.m. Resident R311 stated the following. I haven't gotten a shower since I got here.
Review of Resident R312's clinical record indicated he was admitted to the facility on [DATE].
Review of Resident R311's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/15/24, indicated diagnosis of dysphagia (difficult swallowing), orthostatic hypotension (a form of low blood pressure that happens when standing up from sitting or lying down) and, hyperlipidemia (an abnormally high concentration of fats or lipids in the blood).
Review of Resident 312's care plans dated 4/9/24, indicated to monitor skin during baths and showers as scheduled.
Review of Resident R312's shower documentation dated April 2014, indicated no showers have been provided since date of admission on [DATE].
During a resident council group interview on 4/30/24, at 1:00 p.m. two out of eight residents voiced concerns with receiving shower twice a week.
During an interview on 5/2/24, at 9:32 a.m. Licensed Practical Nurse (LPN) Employee E5 stated: there are shower logs in the shower rooms and the showers are documented in the computer.
During observations on 5/2/24, at 9:35 a.m. observations of the shower rooms on the 400 hall and the 200 hall found no shower logs in the shower rooms.
During an interview on 5/2/24, at 2:11 p.m. the Director of Nursing (DON) confirmed that the facility failed to make certain that showers were consistently provided and failed to provide adequate hygienic care for eight out of 12 sampled residents (Resident R30, R50, R63, R67 R75, R87, R311, and R312 ) as required.
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
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 facility policies, clinical records, facility documents and staff interview, it was determined that the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, facility documents and staff interview, it was determined that the facility failed to ensure that residents received neurological assessment after an incident involving a fall for four of nine residents (Residents R8, R12, R30, and Resident R87).
Findings include:
Review of facility policy Falls Protocol dated 2/1/24, indicated residents experiencing an actual fall will have an immediate assessment by nursing and medical attention will be obtained as needed. Falls that involve a possible head injury will have neurological checks performed and documented.
Review of facility policy Neurological Checks dated 2/1/24, indicated neurological checks shall be performed following an unwitnessed fall or known head injury. Neurological checks should be performed periodically for at least 72 hours. Neurological checks shall be documented on the designated record.
Review of the clinical record indicated Resident R8 was admitted to the facility on [DATE].
Review of Resident R8's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/11/24, indicated diagnoses of hypertension (high blood pressure in the arteries), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and depression.
Review of a nursing progress note dated 2/26/24, indicated Resident R8 was observed sitting on the floor beside her bed. She was unclear if she hit her head. Assisted back to bed. Neuro checks initiated.
Review of the clinical record failed to reveal a neurological assessment was performed for 72 hours following Resident R8's unwitnessed fall on 2/26/24.
During an interview on 5/3/24, at 10:51 a.m. the Assistant Director of Nursing (ADON) confirmed that the facility did not perform a neurological assessment for 72 hours after Resident R8's unwitnessed fall on 2/26/24.
Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE].
Review of Resident R12's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/8/24, indicated diagnosis of high blood pressure, muscle weakness, and dependence on supplemental oxygen.
Review of a nursing progress note dated 4/7/24, indicated Resident R12 was found on the floor by a staff member. Four staff members were required to move Resident R12 away from the bed. Resident R12 was assessed and placed into a chair using a mechanical lift.
Review of the clinical record failed to reveal a neurological assessment was performed for 72 hours following Resident R12's unwitnessed fall on 4/7/24.
During an interview on 5/3/24, at 10:51 a.m. the Assistant Director of Nursing (ADON) confirmed that the facility did not perform a neurological assessment for 72 hours after Resident R12's unwitnessed fall on 4/7/24.
Review of a nursing progress note dated 4/23/24, indicated Resident R12 was found face down on the floor on a fall mat. Neuro checks were initiated and family and the physician were made aware of the fall.
Review of the clinical record failed to reveal a neurological assessment was performed for 72 hours following Resident R12's unwitnessed fall on 4/23/24.
During an interview on 5/3/24, at 10:51 a.m. the ADON confirmed that the facility did not perform a neurological assessment for 72 hours after Resident R12's unwitnessed fall on 4/23/24.
Review of the clinical record indicated Resident R30 was admitted to facility on 2/26/24.
Review of Resident R30's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/2/24, indicated diagnosis of hypertension (high blood pressure in the arteries), multiple sclerosis (a disease that affects central nervous system), and seizure disorder (a disorder in which nerve cell activity in the brain is disturbed, causing seizures.
Review of a nursing progress note dated 4/27/24, indicated Resident R30 was observed face down on the floor beside her bed. Resident was turned on her back. Nursing noticed a laceration above her eye. Resident was assisted back into bed. Resident was sent to emergency room and returned with stitches on her eye brow.
Review of the clinical record failed to reveal a neurological assessment was performed for 72 hours following Resident R30's unwitnessed fall on 4/27/24.
During an interview on 5/3/24, at 10:51 a.m. the ADON confirmed that the facility did not perform neurological assessment for 72 hours after Resident R30's unwitnessed fall on 4/27/24.
Review of clinical record indicated Resident R87 was admitted to the facility on [DATE].
Review of Resident R87's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/1/24, indicated diagnosis of depression, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and heart failure (a progressive heart disease that affects pumping action of the heart muscles).
Review of a nursing progress note dated 3/1/24, indicated Resident R87 was found sitting on the bathroom floor. Resident stated I slipped. Resident unable to describe how fall happened. Resident assessed. No injuries noted. Resident assisted back to bed and placed call bell within reach.
Review of the clinical record failed to reveal a neurological assessment was performed for 72 hours following Resident R87's unwitnessed fall on 3/1/24.
During an interview on 5/3/24, at 10:51 a.m. the ADON confirmed that the facility did not perform a neurological assessment for 72 hours after Resident 87's unwitnessed fall on 3/1/24.
During an interview on 5/3/24, at 10:51 a.m. the ADON confirmed that the facility failed to ensure that residents received neurological assessment after an incident involving a fall for four of nine residents (Resident R8, R12, R30, and R87).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(1) Management.
28 Pa. Code: 207.2(a) Administrator's responsibility.
28 Pa. Code: 211.10(d) Resident care policies.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to mak...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to make certain that weights were monitored for two of nine residents (Resident R21, and R50), failed to timely assess the nutritional status for two of four residents (Resident R21, and R59), and failed to provide nutritional supplements as ordered for weight loss for one of two residents ( Resident R50).
Findings include:
Review of facility policy Resident Weights, dated 2/1/24, indicated that the facility will identify residents at risk for significant weight change and ensure uniform tracking and reporting of resident weights. Monthly weights will be obtained weekly times four weeks following admission/readmission and monthly thereafter. The licensed nurse will notify the Interdisciplinary Team for further assessment.
Review of facility policy Nutriton Management, dated 2/1/24, indicated that based on a resident's comprehensive assessment, the facility will ensure that a resident maintains acceptable parameters of nutritional status, such as body weight and protein levels, unless the resident's clinical condition demonstrates that this is not possible and receives a therapeutic diet when there is a nutritional problem. Suggested parameters for evaluating significance f unplanned weight loss are:
Significant weight loss is defined as:
5% or greater in one month
7.5% or greater in three months
10% or greater in six months.
In evaluating weight loss, the dietitian will consider the resident's usual weight through adult life, and the potential for weight loss to any medical conditions.
Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE].
Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/24, indicated diagnoses of cancer, dementia (a group of symptoms that affects memory , thinking and interferes with daily life), and chronic pain.
Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21 was weighed on 2/1/24 at 115 pounds which reflected a significant weight loss of 10.2% in six months, and that Resident R21 had not been weighed since the 2/1/24/ weight was obtained.
Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21's February weight loss was not addressed in February by the Registered Dietitian (RD) Employee E10.
Review of Resident R50's clinical record indicated she was admitted to the facility on [DATE].
Review of Resident R50's MDS dated [DATE], indicated diagnosis of hypertension (high blood pressure), dementia, and atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat).
Review of Resident R50 's care plan initiated on 3/28/24, indicated to monitor weights.
Review of Resident R50's progress note dated 10/28/23, at 20:58 indicate a weight of 150.5# was recorded for resident for the month of October. This alerts as a -7.5% change [ Comparison Weight 7/12/2023, 163.7 Lbs, -8.1% , -13.2 Lbs ]. Will recommend to begin 60cc TwoCal HN (thickened) BID at med pass. This will provide 240 kcal and 10gm protein a day.
Review of Resident R50's care plan initiated on 11/3/23, indicated to provide nutritional supplement as ordered.
Review of Resident R50's physician orders dated 3/2/24, reveal to weigh resident every month on the day sift.
Review of Resident R50's physician orders dated 11/19/23, reveal to give resident Two Cal (a nutritional supplement) three times a day with medication pass.
Review of Resident R50's clinical record on 5/2/24, at 10:53 a.m. indicated on residents medication administration record (MAR) that Two Cal supplement was unavailable on 4/2/24, 4/4/24, 4/24/24, and 4/27/24.
Review of Resident R50's clinical record on 5/2/24, at 10:55 a.m. indicated that resident was last weighed on 2/9/24.
During an phone interview on 5/3/24, at 10:39 a.m. Registered Dietician, Employee E10 stated that she was not made aware of the facililty not having TwoCal and would have made a recommendation to substitute with another supplement.
Review of clinical record indicated that Resident R59 was admitted to the facility on [DATE].
Review of Resident 59's MDS dated [DATE], indicated diagnoses of diabetes (high sugar level in the blood), high blood pressure, and dysphagia (difficulty swallowing). Section K0520:- Nutritional Approaches, Therapeutic diet was checked, indicating that While a Resident in the past seven days, this nutritional approach was performed.
Review of Resident R59's clinical record failed to reveal nutritional assessment documentation addressing her nutritional status and therapeutic diet captured by MDS dated [DATE].
During an interview on 5/2/24, at 12:59 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed that the facility failed to weigh Resident R21 monthly and to timely assess, and address Resident R21's weight loss, and failed to timely assess the nutritional status of Resident R59.
During a telephone interview on 5/3/24, at 10:50 a.m. RD Employee E10 confirmed that the facility failed to obtain weights monthly as per policy, that not all nutritional evaluations are completed as required in a timely manner, and failed to provide nutritional supplements as ordered for weight loss for one of two residents ( Resident R50).
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care and maintain respiratory equipment for three out of four sampled residents (Resident R3, R12, and R66).
Findings include:
The facility Oxygen administration policy dated 2/1/24, indicated that humidifiers should be labeled and dated with the time changed. At regular intervals, check and clean oxygen equipment, masks, tubing and nasal cannula.
Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].
Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/11/24, indicated active diagnosis of high blood pressure, dementia (a group of symptoms that affects memory, thinking, and interferes with daily life), and muscle weakness.
Review of a physician order dated 1/2/24, indicated to administer supplemental oxygen continuously at 2 liters per minute via a nasal cannula (a lightweight tube placed in the nostrils to deliver oxygen).
Review of a physician order dated 1/2/24, indicated to administer Ipratropium-Albuterol (a medication used to make breathing easier) 0.5-2.5 milligrams, inhale orally every six hours as needed for wheezing and/or shortness of breath.
Review of a physician order dated 4/16/24, indicated to change oxygen tubing, change humidification bottle, and cleanse oxygen filter every night shift every Saturday.
During an observation on 4/29/24, at 10:11 a.m. Resident R3 was observed receiving oxygen at 3 liters per minute via a nasal cannula. A nebulizer machine was located on Resident R3's bedside table. No date was present on the nebulizer tubing and the aerosol face mask was stored inside of an open box of gauze dressings.
During an interview on 4/29/24, at 10:39 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed there was no date on Resident R3's nebulizer tubing and the aerosol mask was improperly stored in an open box of gauze dressings.
Review of the clinical record indicated Resident R12 was admitted to the facility on [DATE].
Review of Resident R12's MDS dated [DATE], indicated diagnosis of high blood pressure, muscle weakness, and dependence on supplemental oxygen.
Review of a physician order dated 10/1/22, indicated to administer oxygen at 2 liters via a nasal cannula as needed for shortness of breath or oxygen saturation less than 90%.
Review of a physician order dated 6/4/23, indicated to change oxygen tubing, change humidification bottle, and cleanse oxygen filter every night shift every Saturday.
During an observation on 4/29/24, at 10:16 a.m. Resident R12 was observed receiving oxygen at 3 liters per minute via a nasal cannula. The humidifier bottle connected to the oxygen concentrator was empty and dated 4/14/24.
During an interview on 4/29/24, at 10:40 a.m. LPN Employee E1 confirmed that Resident R12's humidifier bottle was empty and dated 4/14/24.
Review of Resident R66's admission record indicated she was admitted on [DATE].
Review of Resident R66's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 2/7/24, indicated she had diagnoses that included chronic obstructive pulmonary disease (COPD: a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), peripheral vascular disease (a progressive narrowing of the blood vessels impacting blood flow to the limbs), dementia (a condition characterized by memory loss and progressive or persistent loss of intellectual functioning).
Review of Resident R66's care plan dated 12/6/23, indicated that she is receiving oxygen therapy, change oxygen tubing, change humidification bottle and provide maintenance for oxygen equipment.
Review of Resident R66's physican order dated 5/17/22, indicated to administer oxygen at 2-Liters via nasal cannula every shift for Shortness of breath (SOB).
Review of Resident R66's physician order dated 4/16/24, indicated to change oxygen tubing, Change humidification bottle, cleanse oxygen filter, inspect easy foam wraps (replace if soiled of missing) every night shift every Saturday for Maintenance of oxygen equipment.
During observations on 4/29/24, at 10:19 a.m. Resident R66 was observed sitting in her room. Her oxygen nasal canula tube was above the bridge of her nose. The humidifier water bottle connected to Oxygen concentrator was observed dated 4/14/24.
During an interview on 4/29/24, at 10:20 a.m. Nurse aide (NA) Employee E7 was brought into Resident R66 room and stated: Resident R66's water container is empty and dated 4/14/24. Its not connected to the Oxygen concentrator. Resident R66 oxygen line is dated 4/21/24. Nurses date the oxygen at night and her oxygen is not on her nose.
During an interview on 4/29/24, at 2:05 p.m. the Director of Nursing (DON) confirmed that the facility failed to provide appropriate respiratory care and maintain respiratory equipment for Residents R3, R12, and R66 as required.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected multiple residents
Based on staff interviews, and review of the Food Service Director's Job description, it was determined that the facility failed to employ a full-time qualified Food Service Director for six of six mo...
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Based on staff interviews, and review of the Food Service Director's Job description, it was determined that the facility failed to employ a full-time qualified Food Service Director for six of six months (November and December 2023, and January through April 2024).
Finding include:
Review of the facility's Food Service Director's Job Description indicated that the Food Service Director:
· Must be a graduate of an accredited course in dietetic training approved by the American Dietetic Association.
· Must be registered as a Food Service Director in Pennsylvania.
· Must provide documentation of registry/certificate upon application for the position.
During an interview conducted at initial tour on 4/29/24, at 9:28 a.m. Food Service Director (FSD) Employee E9, stated that he was not a Certified Dietary Manager (CDM) and did not have any formal education or certificates in food service management. FSD Employee E9 stated that he has been a cook in the facility, but was promoted to FSD about six months ago. FSD Employee E9 also clarified that he is not currently enrolled in any classes to become a CDM.
During an additional interview on 4/29/24, at 9:40 a.m. FSD Employee E9 stated that the facility does employ a Registered Dietitian (RD), but that RD Employee E10 comes into the facility only one day per week.
During an interview on 4/29/24, at 1:45 p.m. Nursing Home Administrator (NHA) confirmed that Food Service Director Employee E23 did not possess the appropriate qualifications as required.
28 Pa. Code: 211.6(c)(d) Dietary services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policies, facility documents, and staff interviews, it was determined that the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, facility policies, facility documents, and staff interviews, it was determined that the facility failed to have sufficient dietary staff to perform essential clinical duties for six out of 12 months (November and December 2023, and January through April 2024).
Findings include:
Review of facility policy Resident Weights, dated 2/1/24, indicated that the facility will identify residents at risk for significant weight change and ensure uniform tracking and reporting of resident weights. Monthly weights will be obtained weekly times four weeks following admission/readmission and monthly thereafter. The licensed nurse will notify the Interdisciplinary Team for further assessment.
Significant weight loss is defined as:
5% or greater in one month
7.5% or greater in three months
10% or greater in six months.
Review of Registered Dietitian's Job Description revealed that the purpose of Registered Dietitian's job position is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education, provide nutritional assessment and consultation to assist in planning, organizing and directing the food and nutritional services of the facility. Registered Dietitian must interpret and evaluate information on a patient's chart and make recommendations for appropriate medical nutrition therapy.
Review of the clinical record indicated Resident R21 was admitted to the facility on [DATE].
Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/24, indicated diagnoses of cancer, dementia (a group of symptoms that affects memory , thinking and interferes with daily life), and chronic pain.
Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21 was weighed on 2/1/24 at 115 pounds which reflected a significant weight loss of 10.2% in six months, and that Resident R21 had not been weighed since the 2/1/24/ weight was obtained.
Review of Resident R21's clinical record conducted on 4/30/24, revealed that Resident R21's February weight loss was not addressed in February by the Registered Dietitian (RD) Employee E10.
Review of clinical record indicated that Resident R59 was admitted to the facility on [DATE].
Review of Resident 59's MDS dated [DATE], indicated diagnoses of diabetes (high sugar level in the blood), high blood pressure, and dysphagia (difficulty swallowing). Section K0520:- Nutritional Approaches, Therapeutic diet was checked, indicating that While a Resident in the past seven days, this nutritional approach was performed.
Review of Resident R59's clinical record failed to reveal nutritional assessment documentation addressing her nutritional status and therapeutic diet captured by MDS dated [DATE].
During an interview on 5/2/24, at 12:59 p.m. Licensed Practical Nurse Assessment Coordinator (LPNAC) Employee E2 confirmed that the facility failed to address Resident R21's weight loss, and failed to timely assess the nutritional status of Resident R59.
During a telephone interview on 5/3/24, at 10:39 a.m. RD Employee E10 stated that she began working at the facility one year ago when the census was 70 residents, but that the census has been climbing over the past several months and is now 104. RD Employee E10 confirmed that she is the only employee who performs clinical nutrition evaluations at the facility. RD Employee E10 also stated that she comes into the facility one day per week, as she has a full time job in another facility and works part-time in a third facility. RD Employee E10 confirmed that not all nutritional evaluations are completed as required in a timely manner. RD Employee E10 also stated that since she is only in the facility one time per week she does not participate in residents' care conferences or interdisciplinary team meetings. RD Employee E10 also stated on 5/3/24, at 11:00 a.m. that she does not have enough time to address the current census in one day per week.
During an interview on 5/3/24, at 11:41 a.m. Nursing Home Administrator confirmed that the facility failed to have sufficient dietary staff to perform essential clinical duties for six out of 12 months.
28 Pa. Code: 211.6 (c) 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
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility documents, resident interviews, meal tray observations and staff interviews, it was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility documents, resident interviews, meal tray observations and staff interviews, it was determined that the facility failed to provide menu selections according to the resident's preference for five out of nine residents (Resident R21, R58, R59, R88, and R210).
Findings include:
Review of the facility policy Meal Service Line last reviewed on 2/1/24, indicated that the cook will be stationed at the steam table to place foods from the wells onto the plate in accordance with the menu and resident diet order. Dining Services staff will check the tray for accuracy, cover the plate, and place the tray onto the food cart to be delivered to the floor or unit. The meal service line will be supervised and checked for quality assurance by the Dining Service Manager, Assistant Manager, Supervisor, or Dietitian.
Review of facility Grievance Log dated 3/12/24, revealed that a resident voiced concern as no one had discussed food preferences with the resident.
Review of 3/12/24, Resident Council Meeting Minutes revealed that a resident voiced concern regarding dietary preferences being honored.
Review of 4/9/24, Resident Council Meeting Minutes revealed that a resident voiced concern over not receiving milk on her tray. Another resident voiced concern that the doctor changed her diet to low carbohydrate, but continues to receive a regular diet.
During an interview on 4/29/24, at 12:19 p.m. Resident R59 stated that she often does not receive food items that are on her meal ticket or menu. Resident R59 stated that she asks for additional protein foods on her tray and that this is not always honored.
During an observation on 4/29/24, at 12:19 p.m., Resident R59's meal ticket stated that she was to receive fried chicken, however, there was no fried chicken on her tray and there was a very dry, hard, and stringy appearing piece of meat.
During an interview on 4/29/24, at 12:50 p.m Food Service Director (FSD) Employee E9 stated that the registered dietitian visits the residents for food preferences after admission.
During a lunch meal observation on 4/30/24, the following was noted:
During an interview on 4/30/24, at 12:15 p.m. Resident R88 stated Nobody asks what we like. You just get stuff.
During an observation on 4/30/24, at 12:19 p.m. Resident R21 had breaded chicken and buttered noodles on her meal ticket, but did not have either one of them on her tray. Resident R21 had lasagna on her tray instead.
During an observation on 4/30/24, at 12:23 p.m. Resident R58 had ice cream on her meal ticket, but she had not received it on her tray.
During an interview with Nurse Aide Employee E19 confirmed that Resident R21 and R58 did not receive the foods listed on their meal tickets as stated above.
During an interview on 4/30/24, at 12:32 p.m. Resident R210 stated I get stuff I don't like but I just don't eat it.
During an interview on 5/3/24, at 10:46 a.m. Registered Dietitian (RD) Employee E10 stated that the FSD Employee E9 is to visit residents for food preferences. When RD Employee E10 was told the FSD Employee E9 stated that RD Employee E10 is to do the visits for food preferences, RD Employee E10 stated that she only comes into the facility once a week and not able to visit residents in a timely manner after their admission to obtain food preferences.
During an interview on 5/3/24, at 11:35 a.m. Resident R210 stated that she had never been asked about food preferences since her admission on [DATE], and also added They say I am allergic to fish. But that's not true. I eat fish all the time. Resident R 210 clarified that no one from Dietary Services had ever asked her about any food allergies or preferences.
During an interview on 5/3/24, at 11:40 a.m. Nursing Home Administrator confirmed that the facility failed to provide menu selections in accordance with resident's preferences.
28 Pa Code: 211.6(a)(c ) Dietary service.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0940
(Tag F0940)
Could have caused harm · This affected multiple residents
Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for six...
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Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to implement and maintain an effective training program for six out of eight personnel records (LPN Employee E11, LPN Employee E12, Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15).
Findings include:
The facility Monthly mandatory education schedule last reviewed 2/1/24, indicated that staff will be provided annual inservice training based on the following:
January training (abuse, neglect, elder care justice act)
February training (infection control, bloodborne pathogens, COVID-19).
March training (psychosocial needs, dementia, trauma informed care, substance abuse).
April training (customer service).
May training (resident rights, HIPAA/confidential information, cultural diversity).
June training (falls, restraints, accident, incidents)
July training (fire and safety, disasters, hazards, active shooter).
August training (restorative care, dietary and nutrition, hydration).
September (abuse, neglect, elder care justice act).
October (compliance and ethics).
November (quality assurance performance improvement).
December (infection control, bloodborne pathogens, COVID-19).
Review of Licensed Practical Nurse (LPN) Employee E11's personnel record indicated she was hired on 9/25/95. The record indicated she last received in-service training on 3/2023. Review of Licensed Practical Nurse (LPN) Employee E11's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.
Review of Licensed Practical Nurse (LPN) Employee E12's personnel record indicated she was hired on 10/3/17. The record indicated she last received in-service training on 2/2023. Review of Licensed Practical Nurse (LPN) Employee E12's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.
Review of Nurse aide (NA) Employee E7's personnel record indicated she was hired on 12/18/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E7's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.
Review of Nurse aide (NA) Employee E13's personnel record indicated she was hired on 10/28/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E13's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.
Review of Nurse aide (NA) Employee E14's personnel record indicated she was hired on 11/25/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E14's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.
Review of Nurse aide (NA) Employee E15's personnel record indicated she was hired on 6/4/03. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E15's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year.
During an interview on 5/3/24, at 11:40 a.m. Licensed Practical Nurse (LPN) Infection Control Preventionist and staff educator Employee E16 confirmed that the facility failed to implement and maintain an effective training program for six personnel record as required.
28 Pa. Code 201.19(7) Personnel policies and procedures
28 Pa. Code 201.20(a)(d) Staff development
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0942
(Tag F0942)
Could have caused harm · This affected multiple residents
Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that nurse aide staff received annual inservice train...
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Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that nurse aide staff received annual inservice training on resident rights for four out of four personnel records (Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15).
Findings include:
The certified nursing assistant job description, last reviewed on 2/1/24, indicated that Nurse aides must complete 12 hours of in-service training annually tracked from date of hire. Nurse aides attend mandatory inservice trainings that includes resident rights.
Review of Nurse aide (NA) Employee E7's personnel record indicated she was hired on 12/18/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E7's personnel record did not include annual inservice training on resident rights.
Review of Nurse aide (NA) Employee E13's personnel record indicated she was hired on 10/28/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E13's personnel record did not include annual inservice training on resident rights.
Review of Nurse aide (NA) Employee E14's personnel record indicated she was hired on 11/25/91. The record indicated she last received inservice training on 2/2023. Review of Nurse aide (NA) Employee E14's personnel record did not include annual inservice training on resident rights.
Review of Nurse aide (NA) Employee E15's personnel record indicated she was hired on 6/4/03. The record indicated she last received inservice training on 2/2023. Review of Nurse aide (NA) Employee E15's personnel record did not include annual inservice training on resident rights.
During an interview on 5/3/24, at 11:40 a.m. Licensed Practical Nurse (LPN) Infection Control Preventionist and staff educator Employee E16 confirmed that the facility failed to ensure that nurse aide staff received annual inservice training on resident rights for four personnel records as required.
28 Pa. Code 201.19(7) Personnel policies and procedures
28 Pa. Code 201.20(a)(d) Staff development
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelv...
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Based on review of facility in-service documentation, personnel records, and staff interviews it was determined that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of inservice education training each year for four out of four personnel records (Nurse aide Employee E7, Nurse aide Employee E13, Nurse aide Employee E14, and Nurse aide Employee E15).
Findings include:
The certified nursing assistant job description, last reviewed on 2/1/24, indicated that Nurse aides must complete 12 hours of in-service training annually tracked from date of hire.
Review of Nurse aide (NA) Employee E7's personnel record indicated she was hired on 12/18/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E7's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year. Review of Nurse aide (NA) Employee E7's personnel record did not indicate that 12 hours of inservice training was completed.
Review of Nurse aide (NA) Employee E13's personnel record indicated she was hired on 10/28/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E13's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year. Review of Nurse aide (NA) Employee E13's personnel record did not indicate that 12 hours of inservice training was completed.
Review of Nurse aide (NA) Employee E14's personnel record indicated she was hired on 11/25/91. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E14's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year. Review of Nurse aide (NA) Employee E14's personnel record did not indicate that 12 hours of inservice training was completed.
Review of Nurse aide (NA) Employee E15's personnel record indicated she was hired on 6/4/03. The record indicated she last received in-service training on 2/2023. Review of Nurse aide (NA) Employee E15's personnel record did not include annual inservice training on resident rights, resident confidential information, quality assurance performance improvement (QAPI), falls/incident accident, restorative care, cultural competence, and compliance and ethics in the past year. Review of Nurse aide (NA) Employee E15's personnel record did not indicate that 12 hours of inservice training was completed.
During an interview on 5/3/24, at 11:40 a.m. Licensed Practical Nurse (LPN) Infection Control Preventionist and staff educator Employee E16 confirmed that the facility failed to ensure that all nurse aide staff received a minimum of twelve hours of inservice education training each year for four personnel records as required.
28 Pa. Code 201.19(7) Personnel policies and procedures
28 Pa. Code 201.20(a)(d) Staff development
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility menu, facility documents, observations, staff interviews, and resident interview, it was determine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility menu, facility documents, observations, staff interviews, and resident interview, it was determined that the facility failed to comply with food safety regulations by failing to monitoring the proper cooling of foods for two days (4/27/24, and 4/28/24), and properly store utensils for one of two ice machines (Main Dining Room) creating the potential for food borne illness.
Findings include:
Review of the facility policy Food Temperature Recording Policy dated 2/1/24, indicated that temperatures of un-served/production foods will be taken after meal service/production and followed for six hours (if needed) after service/production for appropiate cooling. All temperature's will be recorded on the Cooling Log. Temperatures of un-served/production foods will be taken prior to the close of the Dining Services department for appropriate cooling and will be recorded on the Cooling Log. If the desired temperature of the un-served/production food is not achieved prior to the close of the dietary department, the food will be discarded.
Review of the facility menu revealed that for Week One Sunday (4/28/24), the main entrée for lunch was [NAME] Pot Roast, and Week One Monday (4/29/24) the alternate main entrée for lunch was roast beef.
During an observation and interview on 4/29/24, at 9:40 a.m. in the Main Dining Room, the ice machine had a scoop that was sitting on top of the ice machine. Food Service Director (FSD) Employee E9 confirmed that the facility failed to prevent any physical contamination and or cross contamination of ice by having an ice scoop on top of the machine.
During an observation on 4/29/24, at 12:19 p.m. Resident R59 had her lunch tray in front of her, but was not eating.
During an observation on 4/29/24, at 12:19 p.m., Resident R59's meal ticket stated that she was to receive fried chicken, however, there was no fried chicken on her tray and there was a very dry, hard, and stringy appearing piece of meat.
During an interview on 4/29/24, at 12:20 p.m. Resident R59 was asked what her entrée was and she replied I think it's left over roast beef from yesterday.
During an interview in Resident R59's room on 4/29/24, at 12:47 p.m. FSD Employee E9 confirmed that Resident R59 was served leftovers from yesterday's lunch of [NAME] pot roast, and confirmed that the meat appeared to be very dry and unappetizing.
During an additional interview on 4/29/24, at 1:08 p.m. FSD Employee E9 stated that [NAME] pot roast was on the menu for lunch on Sunday 4/28/24, but that it was made a day ahead on Saturday 4/27/24, then cooled, and reheated for lunch on Sunday 4/28/24. This was cooled again on 4/28/24, then reheated and reserved for lunch on Monday 4/29/24 as an alternate now called roast beef.
During an interview on 4/29/24, at 1:10 p.m. FSD Employee E9 was asked to produce Cooling Logs to ensure that the meat had undergone proper cooling and temperature monitoring throughout its two separate occasions of cooling.
Review of the facility's Food and Leftover Cooling Log for April 2024 failed to ensure that any documentation for proper cooling was completed for the meat on 4/27/24, or 4/28/24 prior to being served to residents.
During an interview on 4/29/24, at 1:10 p.m. FSD Employee E9 confirmed that the facility failed to provide evidence that the meat temperature was properly monitored and cooled for two days creating the potential for food bore illness.
28 Pa. Code: 201.14(a) Responsibility of licensee
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.6(c) Dietary services.
Feb 2024
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on policy review, observations, and staff interview, it was determined that the facility failed to maintain a clean, comfortable, homelike environment in seven out of 12 sampled resident rooms (...
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Based on policy review, observations, and staff interview, it was determined that the facility failed to maintain a clean, comfortable, homelike environment in seven out of 12 sampled resident rooms (Residents R1, R2, R3, R4, R5, R6, and Resident R7).
Findings include:
The facility Resident environment policy last reviewed 2/1/24, indicated that the facility will provide an environment that is safe, clean, comfortable and homelike.
During a tour with of the facility on 2/26/24, starting at 10:08 a.m. with Environmental services/housekeeping supervisor Employee E1, the following was observed:
At 10:08 a.m. Resident R1's room was observed with white chips and gauges along the wall behind his bed.
At 10:10 a.m. Resident R2's room was observed with white chips and gauges along the wall behind his bed.
staining around the bathroom commode, and brown stains on the corners of the floor.
At 10:14 a.m. Resident R3's room was observed with a white dresser. At the bottom of white dresser was frayed and sharp edges with the potential to lacerate oneself.
At 10:16 a.m. Resident R4's room was observed with her catheter bag leaking on the floor onto the fall mat near her door.
At 10:21 a.m. Resident R5's room was observed with the night light panel glass removed from the night light.
At 10:24 a.m. Resident R6's room was observed with gauges along the wall behind his bed.
At 10:25 a.m. Resident R7's room was observed. His bathroom was observed with black substance lining around the commode and gauges on the wall behind the commode.
During an interview on 2/26/24, at 10:28 a.m. the Environmental services/housekeeping supervisor Employee E1 confirmed that the facility failed to maintain a clean, comfortable, homelike environment in Residents R1, R2, R3, R4, R5, R6, and Resident R7's rooms as required.
28 Pa Code: 207.2(a) Administrator's Responsibility.
28 Pa Code: 201.29(k) Resident Rights.
Jan 2024
7 deficiencies
1 IJ
CRITICAL
(J)
📢 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
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility investigation, resident and staff interviews, it was determined t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility investigation, resident and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent injuries for two of four residents (Resident R3 and R1). This failure caused Resident R3 to have an unsupervised fall causing head trauma, abrasion of nose and fracture of nasal bone and Resident R3 was unsupervised smoking and suffered a burn. Resident R1suffered a fall during care and sustained blunt force injuries of the head and cervical spine from the fall which resulted in the death of Resident R1. This failure created an Immediate Jeopardy situation for two of four residents (Resident R3 and R1).
Findings include:
Review of American Congress of Rehabilitation Medicine - Caregiver Guide and Instructions for Safe Bed Mobility published 4/28/17, indicated bed mobility refers to activities such as scooting in bed, rolling, side-lying to sitting, and sitting to lying down.
Review of the facility policy Anticoagulant Therapy Monitoring reviewed 11/1/23, indicated proper management for anticoagulant therapy is to monitor for signs and symptoms of adverse effects and develop a care plan for resident's receiving anticoagulant therapy.
Review of the facility policy Falls Protocol reviewed 11/1/23, indicated residents determined to be at a high risk for falls will have specific risk factors identified and incorporated into the resident's care plan.
Review of the facility policy Smoking Policy dated 8/16, last reviewed 11/1/23, indicated upon admission, residents who smoke will be reviewed for safety with independence in smoking. Residents who require supervision will be reviewed by the interdisciplinary team to determine appropriate interventions to allow them to smoke in the safest manner possible. Interventions will be individualized based on the needs of the resident. These interventions will include but not limited to; wearing a smoking apron, smoking only when supervised by staff or a responsible party. It stated the facility will make every effort to honor the request of those residents who are supervised with smoking by taking the residents out at their request. The facility may implement smoking times at their discretion based on facility needs. This may include posted smoking times and supervised group smoking. All staff are expected to assist in supervised smoking; it is not the only responsibility of nursing staff. Cognitive status will be identified through the use of the cognitive performance scale. A score of 3 or greater indicates the resident is cognitively impaired. To ensure safety of all residents, smoking supplies for all residents will be kept locked in the medication cart and provided to the resident upon request.
Review of the facility policy Transfer/Lift Policy dated 3/21/16, last revised 1/4/24, indicated all resident care will be provided in a safe, appropriate, and timely manner in accordance with the individual resident's care plan.
Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].
Review of Resident R3's Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 9/8/23, included diagnoses of stroke (the sudden death of brain cells in a localized area due to inadequate blood flow), diabetes (condition that happens when your blood sugar is too high), and high blood pressure. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R3's score to be 3 severe impairment.
Review of Resident R3's care plan dated 9/26/23, indicated the resident will remain free from falls. It was indicated a fall risk assessment was to be completed per protocol.
Review of Resident R3's NSG-MORESE FALL SCALE (PCC) dated 9/11/23, indicated the resident was a moderate risk for falling.
Review of Resident R3's progress note dated 10/24/23, entered by, the former Director of Nursing, Employee E10 stated The resident was outside in his wheelchair and went to the right of the facility entrance. The resident was too close to the sidewalk and curb area of the facility parking lot. The resident one wheel of his wheelchair (left wheel) went off the curb and the resident were off balance and attempted to compensate. He then fell forward onto his left hand, right hand and his face that caused two abrasions to his bridge of his nose. Residents glasses bend from this incident. Resident had epistaxis (nosebleed) that was cleansed, and ice was applied. Resident taking 75 mg Clopidogrel (blood thinner used to prevent heart attacks and strokes in persons with heart disease) daily with a daily 81 mg Aspirin (a nonsteroidal anti-inflammatory drug used to reduce pain, fever, and/or inflammation, and as an antithrombotic (drug that reduces risk of blood clots)). Coagulation status is causing his nose to bleed, occlusive dressing gauze placed in nares to coagulate the resident's active nosebleed. Will complete Neurological checks and vitals to assess if baseline deviates.
Review of Resident R3's progress note dated 10/24/23, at 2:08 p.m. it was indicated the physician was notified and the resident was ordered to pack the left nostril with gauze & apply ice to effected area.
Review of Resident R3's progress note dated 10/24/23, 4:21 p.m. indicated the resident's nose continued to bleed after the fall outside earlier. It was indicated the resident refused to go to hospital previously but was now agreeable to be transferred to the hospital for further evaluation.
Review of Resident R3's hospital Patient Summary dated 10/24/23, indicated the resident sustained blunt head trauma, abrasion of nose, fracture of nasal bone from an accidental fall. The resident nose was packed, and he was ordered to follow up with ENT (Ear, Nose, and Throat) doctor. The resident returned back to the facility.
During an interview on 1/24/24, at 2:56 p.m. the DON confirmed the facility failed to thoroughly investigate and provide adequate supervision which resulted in actual harm, resulting in Resident R3's nose fracture (Resident R3).
Review of Resident R3's care plan dated 11/3/20, stated the resident is dependent on staff for activities and his preferred activities included going outside during supervised smoking times.
Review of Resident R3's care plan dated 9/28/19, revised on 5/5/23, indicated the resident must not be left unattended while smoking, ask staff to light smoking material, wear a smoking apron, be supervised, and place smoking materials at nurses' station for storage.
Review of Resident R3's NSG_SMOKING SAFETY SCREENING V1 assessment dated [DATE], indicated the resident smokes 5-10 cigarettes per day. It was indicated the resident must be provided supervision and a smoking apron while smoking.
Review of Resident R3's progress note dated 10/24/23, at 11:36 p.m. entered by Licensed Practical Nurse (LPN), Employee E11 indicated the resident returned to the facility and was demanding to go outside and smoke. No further action was documented.
Review of Resident R3's progress note dated 10/25/23, at 10:45 p.m. entered by LPN, Employee E11. stated Resident let himself outside to have a cigarette, this writer instructed him to not go outside, it was not time to smoke, instructed him of the designated smoking times for the facility, resident shrugged his shoulders and went outside to smoke anyway. Resident stated, There's no reason why I can't smoke when I want resident refuses to follow rules.
Review of Resident R3's progress note dated 10/26/23, at 1:50 a.m. entered by LPN, Employee E11 stated Resident continues to be non-compliant with the smoking policy, resident has gone outside to smoke several times this shift. Resident states, I'm [AGE] years old, I don't have rules.
Review of Resident R3's progress note dated 10/29/23, at 12:14 a.m. entered by LPN, Employee E11 stated Resident came up to the nurses station and said he was going outside for a quick smoke, this writer explained to him once again it's not his designated smoking time, he cannot go outside at this hour to smoke, resident said, Look the other way then, cause I'm going out resident currently outside smoking, non-compliant with the smoking policy.
Review of Resident R3's progress note dated 10/29/23, at 12:16 a.m. entered by LPN, Employee E11 stated the Registered Nurse (RN) Supervisor was notified of the resident's non-compliance with smoking policy.
Review of Resident R3's progress note dated 10/29/23, at 12:30 a.m. entered by RN, Employee E12 stated resident observed outside front doors sitting in wheelchair smoking. Spoke with resident and reminded of smoking policy. Resident advised that continued non-compliance of smoking policy can result in loss of smoking privilege. Resident unreceptive at this time.
Review of Resident R3's progress noted dated 11/2/23, at 2:29 a.m. entered by LPN, Employee E11 stated Resident continues to go outside and smoke, resident is aware of the smoking policy, resident continues to be non-compliant, RN supervisor aware.
Review of Resident R3's progress note dated 11/2/23, at 2:35 a.m. entered by RN, Employee E12 stated staff observed resident sitting in wheelchair smoking outside front door. Looked for resident outside. Per staff report, resident abruptly went back inside after dropping his lit cigarette on his right leg. Staff further reports resident yelling and brushing lit cigarette off right leg and continuing to slap and pat right leg with both hands to put out burning hole in pants.
Review of Resident R3's progress note dated 11/2/23, at 2:43 a.m. entered by RN, Employee E12 indicated the resident refused to be assessed and stated, leave me alone, I'm fine.
During an interview on 1/25/24, at 9:34 a.m. LPN, Employee E4 stated Resident R3 wants to smoke outside often, and if he comes up to her, she will take a few minutes to go out with him. LPN, Employee E4 stated Resident R3 is never to be left alone while smoking and he should wear a smoking apron.
During an interview on 1/25/24, at 10:19 a.m. Resident R3 stated I go out to smoke by myself all the time.
During an interview on 1/25/24, at 10:35 a.m. with the DON and Registered Nurse Assessment Coordinator (RNAC), Employee E12, the DON stated staff try to supervise him when he goes outside, however he goes around the corner where he is not visible. RNAC, Employee E12 stated he occasionally will sneak around, and staff try to bring him back in or sit with him. RNAC, Employee E12 stated we also have changed our codes a couple times, because he picks up and learns the code and watches and that's how he gets out. The DON confirmed the facility failed investigate Resident R3's incident that occurred on 11/2/23, and to make certain each resident received adequate supervision and assistance which resulted in harm (Resident R3).
Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE].
Review of Resident R1's MDS dated [DATE], included diagnoses of anxiety, depression, bipolar disorder (mental illness characterized by extreme mood swings), psychotic disorder (a severe mental condition in which thought, and emotions are so affected that contact is lost with external reality), dementia (a group of symptoms that affects memory, thinking and interferes with daily life.), and muscle weakness.
Review of Resident R1's care plan dated 11/6/18, indicated the resident was a high risk for falls due to muscle weakness, debility, psychotropic medication use (medications that alter mood, perceptions, and behavior), and abnormalities of gait and mobility. It was indicated the resident must receive an extensive assist of two persons for bed mobility.
Review of Resident R1's [NAME] dated 1/3/24, failed to indicate the resident required an assistance of two people for bed mobility.
Review of Resident R1's physician order dated 3/5/19, indicated to administer 2.5 mg of Eliquis (blood thinner) two times a day for atrial fibrillation (irregular heartbeat).
Review of Resident R1's care plan dated 11/7/21, indicated the resident was on anticoagulant therapy and interventions included to avoid activities that could result in injury, and take precautions to avoid falls.
Review of Resident R1's progress notes dated 1/3/24, entered by RN Supervisor, Employee E5 at 9:45 p.m. stated Resident fell out bed while being changed by the nurse aide. Resident's forehead and nose and was bleeding profusely from the laceration and bleeding a small amount from her nose. Staff LPN had stopped the bleeding with a bath towel. Resident was sitting in an upright position on the floor, with a large amount of blood on the floor, upon RN assessment, resident was talking as she normally does, she was complaining pain to her head. She was answering questions appropriately, Heart Rate 88, pulse ox (measure amount of oxygen in blood) 98%, was unable to get an accurate blood pressure reading resident was irritated with the blood pressure cuff saying it was pinching her. EMS (Emergency Medical Services) arrived and assisted with transferring the resident from the floor to the stretcher. EMS checked resident ' s pupil response and pupils responded within normal limits. Resident was sent to emergency room.
Review of Resident R1's progress note dated 1/4/24, entered by RN Supervisor, Employee E5, at 3:01 a.m. indicated they received a call from the hospital's social worker and wanted to get more information on what happened to the resident because he was unsure of the events and had not got a report from the ambulance. It was indicated that the events the nurse aid told her was that she was changing the resident and she rolled her and her resident fell off the bed and landed face first. It was indicated the resident was not doing well and the recently was comfort measures only.
Review of Resident R1's Emergency Department Note dated 1/3/24, indicated the resident was brought in for evaluation for a fall from a bed. When the resident arrived, she was hypoxic (deficiency in the amount of oxygen reaching the tissues) on room air in the 80's and was having a lot of nasal congestion. It was indicated the resident was on Eliquis and was observed to have multiple areas of ecchymosis (bruising that occurs when blood leaks from a broken capillary into surrounding tissue under the skin), facial ecchymosis, nasal bleeding, and large forehead laceration which is oozing. It stated, after examination it was noted the patient has left both-bone lower leg fractures, nasal bone fractures, and potential ligamentous (painful conditions caused by tearing or overstretching the ligament) injury of her cervical spine. It was indicated Resident R1 was transferred to a trauma center for further treatment and evaluation.
Review of Resident R1's progress note dated 1/4/24, 2:46 p.m. stated per the legal guardian the resident ceased to breath in the hospital.
Review of Resident R1's death certificate dated 1/7/24, indicated the resident cause of death was blunt force injuries of the head and cervical spine from a fall from bed. It was indicated the resident ceased to breath on 1/4/24.
Review of Resident R1's investigation report dated 1/4/24, indicated it was determined NA, Employee E6 failed to follow proper protocol/procedures when rolling resident in bed, resident was rolled away from nurse aide at time of fall.
During an interview on 1/25/24, at 9:36 a.m. LPN, Employee E5 confirmed when turning a resident in bed, you must always roll them towards you and not away. It was indicated a resident's transfer status and level of assistance should be verified in the clinical record, and the facility also implemented a color-coded dot system on all the resident's doors so staff can know how to transfer a resident easily. LPN, Employee E5 stated if a staff member is unsure of the level of assistance a resident requires, they can just ask, and anyone can show them.
During an interview on 1/25/24, at 1:31 p.m. NA, Employee E7 stated when she arrived in Resident R1's room to help, Resident R1 was on the ground and blood was everywhere. It was indicated the resident rolled out of bed and her forehead was observed to be bashed in and her fingers were messed up. NA, Employee E7 stated she was unsure what happened, and that the facility typically has three nurse aides that work that unit, however that day they only had two. NA, Employee E7 stated when assisting a resident who requires the assistance of two people, staff must never transfer them alone. NA, Employee E7 stated she has asked staff from another unit or a nurse for help if she needs assistance.
During an interview on 1/25/24, at 1:40 p.m. LPN, Employee E8 stated she just finished administering Resident R1 her evening medications and was going to lay the head of her bed back when NA, Employee E6 came in and stated, just to leave her go, I was going to assist her with getting ready for bed. LPN, Employee E8 stated she was still outside then door when NA, Employee E6 came out of the room and was speechless a few minutes later. When LPN, Employee E8 entered Resident R1's room, it was indicated the resident was found on the floor, laying on her left side saying, help me. LPN, Employee E8 indicated there was a large amount of blood present and the bed was observed to be pretty high. LPN, Employee E8 stated I was a nurse aide for 10 years, normally when changing them, the bed is lifted to the waistline. LPN, Employee E8 indicated NA, Employee E6 was not that tall and was trying to figure out why the bed was lifted that high. LPN, Employee E8 stated I was literally just in there and she never asked for assistance, I was standing right outside the door, mind you I've been helping them all day. LPN, Employee E8 stated It wouldn't have been an issue if she asked for help.
During an interview on 1/25/24, at 1:46 p.m. NA, Employee E6 stated she was changing Resident R1 in bed with the bed elevated and rolled her away from herself. It was indicated as NA, Employee E6 tucked the brief under Resident R1, she accidently fell out of bed. NA, Employee E6 indicated Resident R1 fell face down and when she ran around the bed to the other side there was blood observed under the resident's head. NA, Employee E6 confirmed a resident's level of assistance is found in the care plan and charting. It was indicated the resident ' s care plan indicated the resident required an assist of two people for bed mobility, however Resident R3's [NAME] failed to specify the number of people needed for bed mobility.
During an interview on 1/25/24, at 1:40 p.m. RN Supervisor, Employee E5 stated when she entered Resident R1's room she was sitting up and staff were holding pressure to her head with a towel. RN Supervisor, Employee E5 stated she should have got help to roll her and I know sometimes when short staffed, they don't always do that.
During a phone interview on 1/25/24, at 2:26 p.m. Protective Service Specialist, Employee E9 indicated it was reported the doctors at the hospital had a concern how Resident R1 received her injuries. It was indicated the injuries did not align with statement. Protective Service Specialist, Employee E9 indicated hospital records revealed a nasal and tibia fracture and spinal injury.
On 1/25/24, at 12:40 p.m. the Nursing Home Administrator and Director of Nursing were provided the IJ template that made the facility aware that an Immediate Jeopardy situation existed for the facility. The facility failed to provide adequate supervision for two of four residents (Resident R3 and R1), which resulted in actual harm. This occurred when the facility failed to provide Residents R1 and R3 the needed supervision to prevent injuries and death. This failure created an Immediate Jeopardy situation for two of four residents (Resident R1 and R3). On 1/25/24, at 6:08 p.m. an acceptable Corrective Action Plan was accepted which included the following interventions:
-The DON or Designees will complete a house audit to identify residents transfer status, level of assistance and supervision. Resident care plans will be reviewed and revised and updated appropriately to reflect resident's current condition. This is to be completed by 1/26/24.
-The Administrator will perform a quality assurance and performance improvement (QAPI) meeting to review and revise policy and procedures for smoking, supervision, and transfer and level of assistance for resident care.
-The Nursing Home Administrator or designees will immediately change the codes to all the doors of the exterior of the building and signage placed at all exterior doors indicating no resident to be outside unaccompanied. This will be completed by 1/25/24.
-The smoking. newly developed supervision policy, and transfer/level of assistance training will be completed with all staff by 1/26/24, at 3:00 p.m.
- Incoming staff will be educated by the RN Supervisor at the start of their shift today. Current employees who are not presently at work will be educated by phone on the abuse policy by 3:00 p.m. on 1/26/24. All agency staff will be educated on the abuse policy prior to the start of their next scheduled shift.
- Staff who received distance education (telephone and email) will sign to acknowledge completion and understanding of education prior to next shift worked.
- The Director of Nursing will complete audits of 15 residents ADL (activities of daily living) care with observations weekly for four weeks, then monthly for three months to validate physician orders for care are followed and staff are aware of resident safety and level of assistance when turning or repositioning a resident in bed. Audits will be completed for smoking times, safety compliance and supervision of residents twice daily for 4 weeks and then five times a week for 3 months. The results of these audits will be forwarded to the monthly Quality Assurance and Performance Improvement Committee for review and frequency of audits.
The NHA changed all the exterior door codes on 1/25/24, and the previous codes were deleted. Signage was observed at all exterior doors indicating no resident to be outside unaccompanied.
During staff interviews conducted on 1/26/24, between 11:49 a.m. and 12:35 p.m. 19 staff members confirmed they received education on proper transfer and level of assistance. Smoking, and supervision.
During staff interviews conducted on 1/26/24, between 12:45 p.m. and 1:29 p.m. 6 staff members confirmed they received education on proper transfer and level of assistance. Smoking, and supervision.
101 of 102 in-house staff were educated on the smoking, newly developed supervision policy, and transfer/level of assistance training. 12 of 12 agency staff were educated on-site from 1/25/24, through 1/26/24, and all ongoing education will be provided to them via phone or on-site prior to the start of their shift.
111 of 111 resident clinical records reviewed on 1/26/24, between 1:32 p.m. through 2:24 p.m. indicated residents' level of supervision, transfer status, level of assistance for care was up to date, accurate, and identified. 10 of 10 resident care plans reviewed, appropriately reflected the resident's transfer status and level of assistance. For residents who are admitted to the facility after 1/26/24, occupational and physical therapy will evaluate the residents within 48 hours of admission. The transfer and level of assistance orders will be entered by the nurse, and care plans will be updated by Registered Nurse Assessment Coordinator (RNAC) or Licensed Practical Nurse Assessment Coordinator (LPNAC).
A supervised smoking audit was conducted by RN Supervisor, Employee E13 on 1/26/24, at 10:00 a.m. and 1/26/24, at 1:30 p.m. The facility was complying.
The Immediate Jeopardy was lifted on 1/26/24, at 3:29 p.m. when the action plan implementation was verified.
During an interview on 1/26/24, at 4:00 p.m. the Nursing Home Administrator and Director of Nursing confirmed the facility failed to provide adequate supervision for two of four residents (Resident R1 and R3), which resulted in actual harm. This occurred when the facility failed to provide Residents R1 and R3 the needed supervision to prevent injuries and death. This failure created an Immediate Jeopardy situation for two of four residents (Resident R1 and R3).
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(e)(1) Management.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(2)(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
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical record, investigation documentations, resident and staff interviews, it wa...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical record, investigation documentations, resident and staff interviews, it was determined that the facility failed to report an allegation of neglect within 24 hours for one out of four sampled residents (Resident R2).
Findings include:
The facility policy Abuse: Protection From Abuse dated 6/23, reviewed 11/1/23, indicated residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect. Regardless of how minor an accident or incident may be, including injuries of unknown source, an investigation must be implemented and witness statements are obtained. An Accident or Incident Report Form must be completed for all reported accident or incidents. It stated neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services, treatment of care, including but not limited to: nutrition, medication, therapies, and activities to daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect.
Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].
Review of the Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 10/24/23, included diagnoses of stroke the sudden death of brain cells in a localized area due to inadequate blood flow.), bipolar disorder (a mental illness characterized by extreme mood swings), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R2's score to be 15, cognitively intact.
Review of Resident R2 investigation report revealed a letter dated 12/29/23, in which Resident R2 stated On Friday, December 29, 2023 I was harassed, lied to, lied on, threatened, humiliated, embarrassed, and physically assaulted. Resident R2 stated Nurse Aide, Employee E3 and LPN, Employee E2 threatened her with the needle and being 302'd. Resident R2 stated this incident has subjected me to more humiliation and evil than I could have surmised. The letter was directed to the Nursing Home Administrator, Director of Nursing, and Ombudsman.
Review of LPN, Employee E2's witness statement dated 12/29/23, indicated Resident R2 was aggressive, agitated, and irritated this shift. It was indicated several staff members, including me, witnessed her be aggressive and rude to her roommate.
Review of Resident R2's investigation report dated 1/1/24, stated Received complaint from resident regarding being given Haldol over the weekend. By her reports she was given the medication against her will.
Review of the facility's incident report dated 1/24/24, failed to include Resident R2's abuse allegation that occurred on 12/29/23 or the resident to resident abuse allegation that occurred on 12/29/23.
Review of incidents submitted to the State did not include the abuse allegation involving Resident R2.
During an interview on 1/14/24, at 10:51 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to report an allegation of neglect within 24 hours involving Resident R2 as required.
28 Pa Code: 201.14 (a ) Responsibility of Management
28 Pa Code: 201.18 (e)(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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate allegations of abuse or neglect for two of five residents reviewed (Resident R2 and Resident R3).
Findings include:
The facility policy Abuse reporting and Investigation dated 8/16, reviewed 11/1/23, indicated the facility will thoroughly investigate all reports of suspected or alleged abuse, neglect, or exploitation. Injuries of unknown origin will be investigated to rule out potential abuse. It stated anyone who witnesses an incident of suspected resident abuse or neglect is to report it to the charge nurse or supervisor immediately.
The facility policy Accidents and Incidents-Investigating and Recording dated 8/16, reviewed 11/1/23, indicated all accidents or incidents occurring on our premises must be investigated and reported to the administrator. It stated regardless of how minor an accident or incident, including injuries of unknown origin, it must be reported to the nursing supervisor and included on the 24-hour report. An investigation must be implemented and witness statements obtained.
The facility policy Abuse: Protection From Abuse dated 6/23, reviewed 11/1/23, indicated residents have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, and neglect. Regardless of how minor an accident or incident may be, including injuries of unknown source, an investigation must be implemented and witness statements are obtained. An Accident or Incident Report Form must be completed for all reported accident or incidents. It stated neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect refers to failure through inattentiveness, carelessness, or omission to provide timely, consistent, safety adequate, and appropriate services, treatment of care, including but not limited to: nutrition, medication, therapies, and activities to daily living. The absence of reasonable accommodations of individual needs and preferences may result in resident neglect.
Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2023, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment
Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].
Review of the MDS dated [DATE], included diagnoses of stroke the sudden death of brain cells in a localized area due to inadequate blood flow.), bipolar disorder (a mental illness characterized by extreme mood swings), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R2's score to be 15, cognitively intact.
Review of Resident R2 investigation report revealed a letter written to the staff of the facility dated 12/30/23, stated On Friday, December 29, 2023 I was harassed, lied to, lied on, threatened, humiliated, embarrassed, and physically assaulted. Resident R2 indicated NA, Employee 14 and NA, Employee E15, as well as the RN Supervisor that was working that evening were witnesses to validate her statement. It was indicated NA, Employee E3 backed LPN, Employee E2 up on the lies of agitating her roommate, and her state of aggression and confusion.
Review of Resident R2's investigation report revealed a witness statement dated 12/29/23, written by Licensed Practical Nurse (LPN), Employee E2. It was indicated several staff member were witnesses, however LPN, Employee E2 failed to list them.
Review of Resident R2's investigation report dated 1/1/24, stated Received complaint from resident regarding being given Haldol over the weekend. By her reports she was given the medication against her will; however, documentation on file indicates that she was having increased agitation and aggression towards her roommate and educated about the medication prior to being given the medication. Documentation indicates that she indicated that she wasn't sure why she was having those behaviors and was receptive to receiving the PRN medication.
Review of Resident R2's investigation dated 1/1/24, failed to include statements from NA, Employee E3, NA, Employee 14, NA, Employee E15, the RN Supervisor, or roommate.
Review of the facility's incident report dated 1/24/24, failed to include Resident R2's abuse allegation that occurred on 12/29/23.
Review of the clinical record indicated Resident R3 was admitted to the facility on [DATE].
Review of Resident R3's Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 9/8/23, included diagnoses of stroke (the sudden death of brain cells in a localized area due to inadequate blood flow), diabetes (a condition that happens when your blood sugar is too high), and high blood pressure. Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R2's score to be 3, severe impairment.
Review of Resident R3's care plan dated 9/28/19, revised on 5/5/23, indicated the resident must not be left unattended while smoking, ask staff to light smoking material, wear a smoking apron, be supervised, and place smoking materials at nurses station for storage.
Review of Resident R3's progress note dated 10/24/23 entered by, DON, Employee E10 stated The resident was outside in his wheelchair and went to the right of the facility entrance. The resident was too close to the sidewalk and curb area of the facility parking lot. The resident one wheel of his wheelchair (left wheel) went off the curb and the resident was off balance and attempted to compensate. He then fell forward onto his left hand, right hand and his face that caused two abrasions to his bridge of his nose. Residents glasses bend from this incident. Resident had epistaxis that was cleansed and ice was applied. Resident taking Clopidogrel 75 mg daily with a daily ASA 81mg. Coagulation status is causing his nose to bleed, occlusive dressing gauze placed in nares to coagulate the residents active nose bleed. Will complete Neurological checks and vitals to assess if baseline deviates.
Review of Resident R3's investigation report for the incident that occurred on 10/24/23, failed to include witness statements from the NA, LPN, and RN Supervisor that was assigned to his care that shift.
Review of the witness statement dated 10/24/23, written by the DON who was the Assistant Director of Nursing at the time, indicated around 12:25 p.m. the former DON, Employee E10 came into the office requesting assistance with Resident R3. It stated when they exited the building the former DON, Employee E10, Scheduler, Employee E16, and the DON found Resident R3 laying in the parking lot with his wheelchair on its side behind him. It was not indicated how long the resident was outside or on the ground.
Review of the witness statement dated 10/24/23, written by Scheduler, Employee E16 it was indicated the former DON, Employee E16 came in from outside and asked for help with Resident R3. It stated once outside, Resident R3 was found on the ground in the front parking lot, it appeared he went off the edge of the sidewalk and fell out of chair. It was not indicated how long resident was on the ground.
Review of Resident R3's investigation report failed to include a witness statement from the former DON, Employee E10, or staff members who were assigned to his care that shift.
Review of Resident R3's progress note dated 11/2/23, at 2:35 a.m. entered by RN, Employee E12 stated staff observed resident sitting in wheelchair smoking outside front door. Looked for resident outside. Per staff report, resident abruptly went back inside after dropping his lit cigarette on his right leg. Staff further reports resident yelling and brushing lit cigarette off right leg and continuing to slap and pat right leg with both hands to put out burning hole in pants.
Review of the facility's incident report dated 1/24/24, failed to include Resident R3's incident that occurred on 11/2/23, while he was smoking unsupervised.
During an interview on 1/25/24, at 10:49 a.m. the Director of Nursing stated the former DON, Employee E10 was responsible for conducting investigation and was unsure why an investigation was not completed. It was confirmed the facility failed to complete an investigation for when Resident R3 allegedly burned himself while smoking outside on 11/2/23.
During an interview on 1/25/24, at 10:51 a.m. the Director of Nursing confirmed the facility failed to complete a thorough investigation that included witness statements for an allegation of abuse and neglect for two of five residents (Resident R2 and Resident R3).
28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.14 (c)(e) Responsibility of licensee.
28 Pa. Code: 201.18 (e)(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
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 policy, clinical records, and staff interview it was determined that the facility failed to provide ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to provide wound dressing treatment as ordered for one out of two residents (Resident R6).
Findings include:
Review of the facility Medication Administration policy dated 8/20, last reviewed 11/1/23, indicated topical medications used in treatments are listed on the E-TAR/E-MAR (electronic treatment administration record and electronic medication administration record).
Review of the facility Resident Rights policy dated 7/23, reviewed 11/1/23, indicated residents have the right to receive the services and items included in the resident's plan of care.
Review of Resident R6's clinical record indicated he was admitted to the facility on [DATE].
Review of Resident R6's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 11/2/23, indicated diagnoses that included venous insufficiency (a condition when blood doesn ' t flow back properly to the heart, causing blood to pool in the veins in your legs), open wound to right foot, and weakness.
Review of Resident R6's care plan dated 12/14/23, indicated the resident had a right foot stasis ulcer. Interventions indicated to apply treatments as ordered.
Review of Resident R6's physician order dated 1/18/24, indicated to apply Xeroform (non-adherent and occlusive sterile wound dressing) to the resident's right dorsal foot, every day shift for his stasis ulcer. It was indicated to cleanse with normal saline (wound cleanser), apply Xeroform to bed, and cover with silicone dressing daily.
Review of Resident R6's January 2024 Treatment Administration Record (TAR) revealed the resident's right foot dressing was not changed as ordered. It was left blank and not signed off for completion.
During an interview and observation on 1/24/24, at 10:18 a.m. Resident R6 stated he did not receive his dressing change yesterday. Resident R6's right foot wound dressing was observed to be soiled, peeling off and it was undated.
During an interview on 1/24/24, at 10:26 a.m. Licensed Practical Nurse (LPN), Employee E20 confirmed Resident R6 dressing was not dated or signed off for completion on 1/23/24. LPN, Employee E20 stated Yesterday was my fault. LPN, Employee E20 stated she forgot to tell the oncoming shift in report
During an interview on 1/24/24, at 11:42 a.m. the Director of Nursing confirmed the facility failed to follow physician orders as ordered for one of two residents (Resident R6).
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records and staff interviews it was determined that the facility failed to ensure...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records and staff interviews it was determined that the facility failed to ensure that a resident's drug regimen was free of unnecessary medication for one of two residents. (Resident R2)
Findings include:
Review of the facility policy Guidelines for Care giver Interaction with Dementia reviewed 11/3/23, indicated staff must interact with residents in a manner that supports dignity and enhances residents ' abilities to successfully participate in life. It was indicated staff must change their thinking from trying to control behavior to understanding and changing the reasons behind the behavior and recognize that the resident cannot always control his/her behavior. It was also indicated staff do not ridicule, scold, or use threatening tone of voice.
Review of the facility policy Right of Refusal reviewed 11/1/23, indicated the resident has the right to refuse treatment. It was indicated the team will assess the resident ' s needs and offer the resident alternative treatments while continuing to provide all other services outline in the care plan. It was indicated should the resident refuse to accept treatment, detailed information relating to the refusal must be entered in to the resident ' s medical record. The attending physician must be notified of such refusal without delay.
Review of the facility policy Restraints reviewed 11/3/23, indicated the resident has the right to be free from any physical or chemical restrain imposed for purposed of discipline or convenience, and not required to treat the resident's medical symptoms. It was indicated chemical restraints is defined as any drug that is used for discipline or convenience and not required to treat medical symptoms.
Review of the clinical record indicated Resident R2 was admitted to the facility on [DATE].
Review of the Minimum Data Set (MDS, federally mandated assessment of a resident's abilities and care needs) dated 10/24/23, included diagnoses of stroke the sudden death of brain cells in a localized area due to inadequate blood flow.), bipolar disorder (a mental illness characterized by extreme mood swings), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: Cognitive Patterns, Questions C0500 BIMS Summary Score revealed Resident R2's score to be 15, cognitively intact.
Review of Resident R2's care plan dated 7/31/20, indicated the resident has a psychosocial well-being problem, and it was indicated the resident needs assistance, encouragement, and support to identify problems that cannot be controlled. It was indicated Resident R2 needs time to talk, and staff must encourage the resident to express feelings of anxiousness and lack of patience.
Review of Resident R2's physician orders active in December 2023, included:
-Haldol 5mg/ml, inject 2 mg intramuscularly (IM) one time a day for agitation, aggression, irritation for 12/29/23.
-Resident R2's active physician orders in December 2023 failed to include an order for any other psychotropic drugs.
Review of a progress note written by Licensed Practical Nurse (LPN), Employee E2 on 12/29/23, at 8:45 p.m. stated Resident has been agitated, aggressive, and irritated for the duration of this shift, several staff members has witnessed this resident get physical and yell at roommate causing the roommate to exhibit s/s of triggers. it was indicated the resident was displaying manic and aggressive behaviors. LPN, Employee E2 documented This nurse called on call to get an STAT IM order for Haldol or Ativan to help calm this resident down, resident left in room with staff nearby for safety, this nurse awaiting a call back from on call doctor with new order, will continue to monitor.
Review of a progress note written by Licensed Practical Nurse (LPN), Employee E2 on 12/29/23, at 8:57 p.m. stated the on-call nurse practice called back, and an one-time STAT order for IM Haldol 2mg was verbally given.
Review of Resident R2's December MAR indicated the resident received 2mg of 5mg/ml Haldol IM Injection in the left deltoid at 9:16 p.m. which was administered by LPN, Employee E2.
Review of Resident R2's investigation report dated 1/1/24, stated Received complaint from resident regarding being given Haldol over the weekend. By her reports she was given the medication against her will.
Review of Resident R2 investigation report revealed a letter dated 12/30/23, that indicated Resident R2 received Haldol against her will.
Review of LPN, Employee E2's witness statement dated 12/29/23, indicated Resident R2 was aggressive, agitated, and irritated this shift. A review of LPN, Employee E2 witness statement failed to indicate what non-pharmacological interventions were implemented prior to obtaining an order for IM Haldol.
During an interview on 1/24/24, at 10:59 a.m. Resident R2 stated an incident took place not that long along in which staff stated she hit her roommate with a stick and she would be 302'd or given a shot. She indicated she was begging not to receive the shot or be 302'd. She stated two aides told the nurse I didn't need it, but because I seemed agitated, they gave me Haldol I didn't need.
During an interview on 1/25/24, at 9:34 a.m. LPN, Employee E4 stated if a resident is experiencing behaviors, staff should first ask what's going on to find out the root cause. LPN, Employee E4 stated non-pharmacological interventions always must be tried to fix the problem before administering psychotropic medications. LPN, Employee E4 stated medications are the last resort.
During a phone interview on 1/25/24, at 10:51 a.m. LPN, Employee E2 confirmed she administered a one-time dose of Haldol to Resident R2. LPN, Employee E2 stated she turned on the resident's TV, told her to put headphones on, and tried to see if she could move her to another room, however that wasn't possible, so she tried to close the curtain, and Resident R2 didn't want it closed. When LPN, Employee E2 was asked if she documented the non-pharmacological interventions, she stated I believe I did document non-pharmacological interventions, especially the curtain.
During an interview on 1/25/24, at 11:06 a.m. Nurse Aide (NA), Employee E3 stated LPN, Employee E2 said Resident R2 needs the shot, not her roommate, I'm going to get it ordered, if you want to come back in room and hold her down if she gets combative. It was indicated when they arrived back in Resident R2's room with the Haldol, Resident R2 told LPN, Employee E2 that I am not taking a shot or 302'd, and LPN, Employee E2 stated you don't have an option and threatened to 302 her, so she accepted the shot. NA, Employee E3 stated Resident R2 has never acted like that before, it was a new thing for her.
During an interview on 1/25/24, at 10:51 a.m. the Director of Nursing (DON) confirmed that the facility failed to ensure that a resident's drug regimen was free of unnecessary medication and medication was provided as per order for Resident R1 as required.
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 201.18(e)(1) Management.
28 Pa. Code: 211.9(a)(1)(g) Pharmacy services.
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 a review of facility policies, documents, resident council minutes and staff interviews it was determined that the facility failed to implement the grievance process in accordance with Federa...
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Based on a review of facility policies, documents, resident council minutes and staff interviews it was determined that the facility failed to implement the grievance process in accordance with Federal regulations for five of five residents (Resident R4, R5, R6, R7, and R8).
Findings include:
Review of the facility policy Resident Rights reviewed 11/1/23, indicated the facility will protect and promote the rights of each resident. It stated a resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. It was indicated residents have the right to have grievances promptly resolved, in accordance with law.
Review of the facility resident council meeting minutes dated 1/9/24, indicated to maintain the integrity of confidentiality, this month's resident council was performed 1:1. It was indicated there were concerns identified regarding staff being rude, failing to answer call lights in a timely manner, and assist a resident back to bed.
Review of a grievance filed by Resident R4 on 1/9/24, stated it takes long for aides to answer the call light and they are rude to her. It was indicated it takes up to thirty to sixty minutes on second shift. For the immediate action and investigative steps taken it was indicated the facility was unable to determine specific worker involved. It stated facility wide education initiated. The grievance concern was signed and dated by the Director of Nursing (DON) and Nursing Home Administrator (NHA) on 1/15/24.
Review of a grievance filed by Resident R5 on 1/9/24, stated that it takes a long time for aides to answer the call light on second shift. For the immediate action and investigative steps taken it was indicated the facility was unable to determine specific worker involved. It stated facility wide education initiated. The grievance concern was signed and dated by the DON and NHA on 1/15/24.
Review of a grievance filed by Resident R6 on 1/9/24, stated his call bell is not answered in a timely manner. It was indicated this occurs mostly on second shift. For the immediate action and investigative steps taken it was indicated the facility was unable to determine specific worker involved. It stated facility wide education initiated. The grievance concern was signed and dated by the DON and NHA on 1/15/24.
Review of a grievance filed by Resident R7 on 1/9/24, indicated it takes too long for aides to answer her call light. It was indicated this occurs mostly on second shift. For the immediate action and investigative steps taken it was indicated the facility was unable to determine specific worker involved. It stated facility wide education initiated. The grievance concern was signed and dated by the DON and NHA on 1/15/24.
Review of a grievance filed by Resident R8 on 1/9/24, indicated the resident was up in her chair from noon until 10:00 p.m. It stated she asked numerous times to go to bed. It was indicated this occurred on the evening shift of 1/8/24. For the immediate action and investigative steps taken it was indicated the facility was unable to determine if event happened and staff do not recollect resident requesting to return to bed. The grievance concern was signed and dated by DON and NHA on 1/15/24.
A review of the facility's grievance log and resident council minutes including concern resolutions failed to provide evidence that the facility implemented a grievance process that included making certain that all written grievance decisions include the steps taken to investigate the grievance and a summary of the pertinent findings or conclusions regarding the resident's concerns.
During an interview on 1/25/24, at 6:15 p.m. the DON confirmed the facility does not have evidence the concerns identified at January's resident council meeting were thoroughly investigated. The DON stated I don't see why those concerns would require an investigation. The NHA confirmed that the facility failed to implement the grievance process and properly investigate the resident's concerns voiced during the Resident Council Meetings.
Pa Code: 201.18(e)(4) Management
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 F0725
(Tag F0725)
Could have caused harm · This affected multiple residents
Based on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nu...
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Based on review of facility policy, resident observations, resident interviews and confidential staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of seven of ten residents (Resident R2, R4, R5, R6, R7, R8, and R9).
Findings Include:
Review of the undated, Certified Nursing Assistant job description indicated it is the responsibility of nurse aides to assist residents with bath functions, nail care, and bladder and bowel functions.
During an interview on 1/24/24, at 9:57 a.m. Nurse Aide (NA), Employee E17 stated there can be an improvement with staffing. She stated she is unable to provide care to the residents and is often overwhelmed. It was indicated she has worked as a nurse aide for 30 years and it hasn't been this bad.
During an interview on 1/24/24, at 10:03 a.m. NA, Employee E18 stated we can always use staff and the weekends are worse. NA, Employee E18 stated resident's showers have to be rescheduled at times, and there are not enough staff to safely transfer residents. It was indicated staff are not always able complete documentation before the end of their shift. Some people have to wait to eat, usually a half hour. We definitely can use staff. We went from three on a hall, to now two, sometimes two and a float. NA, Employee E18 stated the workload has increased big time and it does get overwhelming, these people deserve better honestly.
During an interview on 1/24/24, at 10:08 a.m. Resident R9 stated the call bell response was long, sometimes up to a half hour. Resident R9 stated he gets a shower about every two weeks and it's been a while since he was last showered.
Review of the facility provided undated Shower list indicated Resident R9 was scheduled to receive a shower every Friday on day shift and Tuesday on afternoon shift.
Review of Resident R9's 30 day bathing task report on 1/24/24, it was documented Resident R9 received a bed bath on 1/5/24, and 1/12/24.
Review of Resident R9's clinical record failed to reveal documentation that Resident R9 was offered a shower as scheduled every Tuesday and Friday.
During an interview on 1/24/24, at 10:14 a.m. NA, Employee E19 stated we run very short when asked about staffing. It was indicated there are times staff cannot get the job done. NA, Employee E19 stated it's difficult to do nail care or hair care, and showers are often rescheduled or pushed back. NA, Employee E19 stated residents get up on their own, and if they need an assist of two people, I have no choice to help them with one. It was indicated there is not enough time to document.
During an interview and observation on 1/24/24, at 10:18 a.m. Resident R6 stated the facility needs more staff and he did not receive his dressing change yesterday. Resident R6's wound dressing was observed to be peeling off and it was undated. Resident R6 indicated a concern with the length of time it takes for call bells to be answered. It was indicated it can take up to an hour at times.
During an interview on 1/24/24, at 10:26 a.m. Licensed Practical Nurse (LPN), Employee E20 confirmed Resident R6 dressing was not dated or signed off for completion on 1/23/24. LPN, Employee E20 stated Yesterday was my fault and I was flustered. LPN, Employee E20 stated staffing sucks and it can interfere with duties. I will do med pass, then I go and help LPN, Employee E20 stated.
During an interview on 1/24/24, at 10:40 a.m. Resident R10 stated he had an incident about a month and a half ago when he wasn't able to get up until 2 o'clock in the afternoon, it irritated me.
During an interview on 1/24/24, at 10:53 a.m. NA, Employee E21 stated staff are unable to safely transfer, assist, and shower residents. It was indicated staff do the bare minimum and weekends are worse.
During an interview on 1/24/24, at 10:59 a.m. Resident R2 stated this used to be a very nice place ,and two to three people, now all of a sudden, there's one person taking care of a hall. It was indicated staff have to run and find help. Resident R2 stated if I need help being pulled up, it can take an hour. Resident R2 indicated when it comes to the restroom it can take up to a half hour to get assistance and staff are running around like chickens with their head cut off. Resident R2 stated she is scheduled showers every Tuesday and Friday, however people on Friday are so hectic, I just say forget it.
Review of the facility provided undated Shower list indicated Resident R2 was scheduled to receive a shower every Tuesday on day shift and Friday on evening shift.
Review of Resident R2's 30 day bathing task report on 1/24/24, indicated the resident received one bed bath on 1/2/24, and one shower on 1/16/24.
Review of Resident R2's clinical record failed to reveal documentation that Resident R2 was offered a shower as scheduled every Tuesday and Friday.
During an interview on 1/25/24, at 4:06 p.m. LPN, Employee E22 confirmed the facility failed to documented that Resident R2 and R9 were offered showered on their scheduled days.
Review of a grievance filed by Resident R4 on 1/9/24, stated it takes long for aides to answer her call light and then are rude to her. It was indicated it takes up to thirty to sixty minutes on second shift.
Review of a grievance filed by Resident R5 on 1/9/24, stated that it takes a long time to and call light on second shift.
Review of a grievance filed by Resident R6 on 1/9/24,stated his call bell is not answered in a timely manner. It was indicated this occurs mostly on second shift.
Review of a grievance filed by Resident R7 on 1/9/24, indicated it takes too long for aides to answer her call light. It was indicated this occurs mostly on second shift.
Review of a grievance filed by Resident R8 on 1/9/24, indicated the resident was up in her chair from noon until 10:00 p.m. It stated she asked numerous times to go to bed. It was indicated this occurred on the evening shift of 1/8/24.
Review of Resident Council minutes dated 1/9/24, identified the concerns mentioned above.
During an interview on 1/25/24, at 1:40 p.m. RN Supervisor, Employee E5 indicated nurse aides do not always get help for residents that require an assist of two people when short-staffed.
During an interview on 1/24/24, at 6:15 p.m. the Director of Nursing and Nursing Home Administrator confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of seven of ten residents (Resident R2, R4, R5, R6, R7, R8, and R9).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(6) Management.
28 Pa. Code: 201.20(a) Staff development.
28 Pa. Code: 211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.
Jan 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observations, review of clinical records, facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an effective infection prevention a...
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Based on observations, review of clinical records, facility policies and documentation, and staff interviews, it was determined that the facility failed to maintain an effective infection prevention and control program by failing to follow infection control guidelines from the Pennsylvania Department of Health (PA DOH) to reduce the spread of infections. This failure resulted in seven of ten residents not positive for COVID-19 remaining in room with a resident with a COVID-19 positive resident (Residents R2, R4, R6, R8, R10, R12, and R14) and two of seven residents who remained in a room with a COVID-19 positive resident becoming positiveand symptomatic of COVID-19 (Residents R2 and R4).
Findings include:
Pennsylvania Health Alert Network (PA-HAN) - 694, Interim Infection Prevention and Control
Recommendations for COVID-19 (a contagious viral disease that can cause a variety of symptoms, including breathing problems, fever, and cough) in Healthcare Settings dated 5/11/23, indicated Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. If cohorting (placing residents with a shared condition together), only patients with the same respiratory pathogen should be housed in the same room.
Review of the COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care dated July 2023, provided a Resident Cohorting Guide, which that when Resident A is positive for COVID-19, they should not be cohorted with Resident B, when Resident B has no respiratory symptoms and not in isolation.
Review of the facility policy Coronavirus Protocol and Guidance dated 5/15/23, indicated to place the individual in a private room (if available) with a closed door and dedicated bathroom. If a private room is unavailable, residents with CONFIRMED COVID-19 may be cohorted together.
Review of daily census information indicated that Resident R1 and R2 were roommates. Review of facility documentation indicated that Resident R1 resulted as positive on 12/22/23. Both residents remained in the same room, with Resident R2 then testing as positive for COVID-19 on 12/27/23. Review of a progress note on 12/30/23, at 9:45 p.m. indicated that Resident R2 had a congestion. Review of facility census data indicated that on 12/22/23, the facility had 31 beds not assigned to residents.
Review of daily census information indicated that Resident R3 and R4 were roommates. Review of facility documentation indicated that Resident R3 resulted as positive on 12/26/23. Both residents remained in the same room, with Resident R4 then testing as positive for COVID-19 on 12/30/23. Review of facility census data indicated that on 12/26/23, the facility had 30 beds not assigned to residents.
Review of daily census information indicated that Resident R5 and R6 were roommates. Review of facility documentation indicated that Resident R5 resulted as positive on 12/22/23, and was sent to the hospital that same day. Resident R6 remained in the shared room. On 12/24/23, Resident R5 returned to the facility, returning to the same shared room. Review of facility census data indicated that on 12/22/23, the facility had 31 beds not assigned to residents.
Review of daily census information indicated that Resident R7 and R8 were roommates. Review of facility documentation indicated that Resident R7 resulted as positive on 12/23/23. Both residents remained in the same shared room. Review of facility census data indicated that on 12/23/23, the facility had 31 beds not assigned to residents.
Review of daily census information indicated that Resident R9 and R10 were roommates. Review of facility documentation indicated that Resident R9 resulted as positive on 12/24/23. Both residents remained in the same shared room. Review of facility census data indicated that on 12/23/23, the facility had 30 beds not assigned to residents.
Review of daily census information indicated that Resident R11 and R12 were roommates. Review of facility documentation indicated that Resident R11 resulted as positive on 12/26/23. Both residents remained in the same shared room. Review of facility census data indicated that on 12/26/23, the facility had 30 beds not assigned to residents.
Review of daily census information indicated that Resident R13 and R14 were roommates. Review of facility documentation indicated that Resident R13 resulted as positive on 12/30/23. Both residents remained in the same shared room. Review of facility census data indicated that on 12/26/23, the facility had 26 beds not assigned to residents.
During an observation on 1/2/24, at 10:15 a.m. Resident R7's room door was observed open.
During an observation on 1/2/24, at 10:28 a.m. Resident R7's room door was observed open.
During observations conducted on 1/2/24, between 11:40 - 11:50 a.m. revealed that Resident R2's room door was open, Resident R3 and R4's room door was open, Resident R9 and R10's room door was open, and Resident R13's room door was open.
During an interview on 1/2/24, at approximately 2:00 p.m. the Director of Nursing confirmed that when a resident was diagnosed with Covid-19, they remained in the same room with a non-positive resident.
During an interview on 1/2/24, at approximately 3:30 p.m. the Nursing Home Administrator confirmed that the facility failed to maintain an effective infection prevention and control program by failing to follow infection control guidelines from the PA DOH to reduce the spread of infections. This failure resulted in seven of ten residents not positive for COVID-19 remaining in rooms with a resident positive with COVID-19, and two of seven residents who remained in a room became positive with COVID-19.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code:201.18(e)(6) Management.
28 Pa. Code:211.12(a)(c)(d)(1)(2)(3)(4) Nursing services.
Sept 2023
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
Deficiency F0836
(Tag F0836)
Could have caused harm · This affected 1 resident
Based on review of facility financial documents, interviews with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents'...
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Based on review of facility financial documents, interviews with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are potentially impacted.
Findings include:
28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations, subsection 201.14(g), dated July 1, 2023, indicated that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are jeopardized.
Review of facility provided Accounts Payable Ledger 1 on 9/13/23, at 11:53 a.m. indicated Nursing Staffing Agency 1 with an outstanding balance of $9,195.30 for services from 6/7/23 -8/2/23.
Interview with Nursing Home Administrator on 9/13/23, at 1:00 p.m. indicated that they solely used Nursing Staffing Agency 2 as their primary vendor for nursing staff vacancies for the past three months or so and that Nursing Staffing Agency 1 didn't send them anybody.
Review of facility provided Accounts Payable Ledger 1 did not indicate Nursing Staffing Agency 2 as a vendor. Further interview with the Nursing Home Administrator indicated he was not aware of why the vendor was not listed and would reach out to the home office.
Information from Nursing Staffing Agency 3 indicated $1,040 plus interest was owed to the vendor from the facility.
Review of facility provided Accounts Payable Ledger 1 did not indicate Nursing Staffing Agency 3 as a vendor.
Interview with the Nursing Home Administrator on 9/13/23, at 1:15 p.m. indicated there was an invoice from Nursing Staffing Agency 3 and the facility owed approximately $1,000 and confirmed Nursing Staffing Agency 3 was not on the Accounts Payable Ledger1.
Interview with Licensed Practical Nurse (LPN) Employee E1 on 9/13/23, at 1:20 p.m. indicated working for Nursing Staffing Agency 2 and that they were scheduled at this facility through Friday, September 22, 2023. After that Nursing Staffing Agency 2 was not posting shift vacancies for this facility due to nonpayment of balance owed to vendor.
Review of facility provided Accounts Payable Ledger 2 received on 9/13/23, at 2:07 p.m. indicated Nursing Staffing Agency 1 with a balance of $4,205.70 for services from 7/19/23 - 8/2/23 and did not include Nursing Staffing Agency 3's owed balance of $1,040.
Further review of the facility provided Accounts Payable Ledger 2 on 9/13/23, at 2:15 p.m. indicated Nursing Staffing Agency 2 with an owed balance of $20,449 for services from 8/2/23.
Interview with the Director of Nursing and Nursing Home Administrator on 9/13/23, at 2:30 p.m. indicated they were reviewing three invoices totaling $90,000 from Nursing Staffing Agency 2 yesterday due to elevated rates on the weekends. They indicated Nursing Staffing Agency 2 would honor the schedule up to next Friday and would not fill vacancies after if payment was not received.
Interview with the Nursing Home Administrator on 9/13/23, at 2:40 p.m. indicated that they have approximately 10 registered nurses and licensed practical nurses in management that are willing to work twelve hour shifts in the event a solution is not rendered with Nursing Staffing Agency 2 as an Emergency Staffing Plan for back up and confirmed the facility failed to pay bills in a timely manner for services without which the residents' health and safety are potentially impacted.
28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management
28 Pa Code: 201.18 (b)(1) (e)(1) Management.
Jun 2023
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of neglect for one out of three sampled resident records (Resident R30).
Findings include:
The Abuse reporting policy dated 8/2016, and last reviewed 1/23/23, indicated that the facility will thoroughly investigate all reports of suspected or alleged abuse, neglect or exploitation. Injuries of unknown origin will be investigated to rule out potential abuse. The facility shall notify the Department of Health in compliance with Federal and State regulation. The Pennsylvania Department of Health will be notified of the alleged event via the electronic reporting system.
Review of Resident R30's admission record indicated she was admitted on [DATE].
Review of Resident R30's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) 3/18/23, indicated she was admitted with diagnoses that included acute kidney failure (gradual loss of kidney function), hyperlipidemia (elevated lipid levels within the blood), Hemiplegia (paralysis on one side of the body), and history of breast cancer. Review of Resident R30's MDS indicated the diagnoses were the most recent upon review.
Review of Resident R30's care plan dated 3/16/23, indicated Resident R30 needs assistance with changing position in bed, assistance with bed mobility, and is a hoyer lift with all transfers out of bed.
Review of Resident R30's incident report dated 3/26/23, indicated that Resident R30 was on the floor and Registered Nurse (RN) Employee E2 was notified. Nurse Aide Employee E3 stated that while change Resident R30 was rolled onto her left side. Nurse aide Employee E3 was standing on the right side of the bed. Resident R30 legs started to slide off the bed and Nurse Aide Employee E3 held onto Resident R30, walked around to the other side of the bed, braced Resident R30 fall and lowered her to the floor. Resident R30 sustained a skin tear to the left forearm (7 cm x .0.5 cm). A dressing was applied to the area. Resident R30 was assisted back to bed with a hoyer lift and two-person assistance.
Review of incidents of neglect reported to the local State field office did not include the incident involving Resident R30.
On 6/8/23, Registered Nurse (RN) Employee E2 was called for an interview and did not answer the phone or reply for an interview.
During an interview on 6/08/23, at 11:44 a.m. interview Nurse Aide Employee E3 stated she has been an aide for 23 years. She stated she provided a statement about the incident. She stated on 3/16/23, she was changing Resident R30 in the bed. Nurse Aide Employee E3 rolled Resident R30 over by telling her to roll over to her right. Nurse Aide Employee E3 crossed Resident R30 legs over and she grabbed the rail. Resident R30 kept rolling. Nurse Aide Employee E3 felt the weight of her body was sliding. Nurse Aide Employee E3 ran around the bed. As Resident R30 was going down, Nurse Aide Employee E3 got under Resident R30 slid down on top of Nurse Aide Employee E3. Nurse Aide Employee E3 stated she typically rolls the residents towards herself. Nurse Aide Employee E3 did not get anyone to help because she had changed Resident R30 before. Nurse Aide Employee E3 stated Resident R30 was rolled away from her during the incident. Nurse Aide Employee E3 did check the mobility in the [NAME] ([NAME]-document explaining level of care needed) before moving Resident R30. Nurse Aide Employee E3 stated she received retraining after this incident.
During an interview on 6/9/23, at 11:23 a.m. the Director of Physical Rehabilitation Services Employee E9 stated that rolling a resident away during bed mobility is not appropriate. Staff have been educated multiple times to roll towards oneself and that Resident R30 is dependent for bed mobility.
During an interview on 6/9/23, at 11:34 a.m. the Director of Nursing (DON) confirmed that the facility failed to report an allegation of neglect involving Resident R30 as required.
28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management
28 Pa Code: 201.18 (b)(1) (e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, staff interview it was determined that the facility failed to implem...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, staff interview it was determined that the facility failed to implement a care plan for assistance with eating for one of four residents (Resident R1).
Findings include:
Review of facility policy MDS/RAI/Care Planning dated 3/12/23, indicated: Develop a written plan of care individualized for each resident , which identifies through an assessment process his/her strengths, problems and needs.
Review of Resident R1 clinical record was admitted [DATE], with the following diagnosis of dystonia ( a state of abnormal muscle tone, resulting in muscular spasm and abnormal posture) and aphasia (a disorder that affects how you communicate). These diagnosis remained current as of the MDS (minimum data set a periodic assessment of resident needs ) dated 12/1/23.
Review of incident Choking dated 12/15/23, indicated that Resident R1 was heard coughing, NA (Nurse Aide) Employee E10 went in and Resident R1 indicated that he was choking. NA Employee E10 went and got a nurse who used a suction machine, with three pieces of grilled cheese removed from Resident R1 airway.
During an interview on 6/8/23, at 11:25 a.m. NA Employee E10 indicated that they were assisting Resident R1 with eating, per NA Employee E10 Resident and families preference is to assist Resident R1 with food, and then to leave - Resident R1 will ring call bell when ready to take next bite.
NA Employee E10 was in hallway and heard coughing from Resident R1 room - which per NA was unusual. When NA Employee E10 went in room Resident R1 signaled they were choking. During interview NA Employee E10 indicated that this was Resident R1 preference to eat and ring bell as it can take two hours for Resident R1 to eat and they do not want staff staring at them waiting to finish eating.
Review of Resident R1 care plan failed to include the specifics of how Resident R1 preferred to eat.
Review of Resident R1 [NAME] (a form used to assist staff with residents care needs), failed to indicate how Resident R1 was to be assisted with eating,
During an interview on 6/9/23, at 12:25 p.m. Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that the facility failed implement a care plan for Resident R1 eating needs.
28 Pa. Code. 211.10 c Resident care policies.
28 Pa. Code 211.11 (a)(b)c(d)Resident care plan.
28 Pa. Code 211.12 c(d)(1)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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as per order for one out of three residents (Resident R37).
Findings include:
The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating.
The facility Nursing care of the diabetic resident policy dated 3/12/23, indicated that staff will document the results of fingerstick blood glucose monitoring, document interventions to stabilize glucose levels, and document the notification to the physician.
The facility Glucose Monitoring policy dated 3/12/23, indicated monitoring blood glucose levels includes checking the physician's order, document the date, time and glucose level, and if the glucose level was above or below the parameter range to document the time the physician was notified.
Review of Resident R37's was originally admitted on [DATE].
Review of Resident R37's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 3/15/23, indicated that he was admitted with diagnoses that included diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), chronic obstructive pulmonary disease (a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), and hypertension (a condition impacting blood circulation through the heart related to poor pressure). The MDS indicated that these diagnose were current upon review.
Review of Resident R37's care plan dated 2/20/23, indicated to monitor, document and notify the physician of hyperglycemia and hypoglycemia.
Review of Resident R37's physician order dated 3/28/23, indicated to administer insulin subcutaneously via insulin pen before meals and at bedtime using blood glucose monitoring and the following protocol:
151-200=1 units
201-250=2 units
251-300=3 units
301-350=4 units
351-400=5 units
400-600=10 units and call the doctor
Review of Resident R37's blood glucose vital summary dated September indicated the following:
4/11/23- 485 mg/dl
4/12/23- 593 mg/dl
4/16/23- 600 mg/dl
4/20/23- 474 mg/dl
4/25/23- 541 mg/dl
Review of Resident R37's clinical progress notes did not include physician notifications for the abnormal glucose levels for 4/11/23, 4/12/23, 4/16/23, 4/20/23 and 4/25/23.
During an interview on 6/07/23, at 11:55 a.m. the Director of Nursing (DON) stated that there are no physician notifications for the abnormal glucose levels for 4/11/23, 4/12/23, 4/16/23, 4/20/23 and 4/25/23.
During an interview on 6/08/23, at 9:24 a.m. Registered Nurse (RN) Supervisor Employee E4 confirmed that the facility failed to notify a physician of abnormal glucose readings via a CBG levels as per order for Resident R37 as required.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record and staff interview it was determined that the facility failed to provide a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record and staff interview it was determined that the facility failed to provide a diagnosis for a psychotropic medication for one of five Residents (Resident R54).
Findings include:
Review of facility policy Antipsychotic Drugs dated 1/23/23, indicated: Residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record.
Review of Resident R54 clinical record indicated admission on [DATE], with the diagnosis of major depressive disorder recurrent (type of clinical depression - persistently depressed mood).
Additional review of Resident R54 clinical record - physician orders dated 5/1/23, indicated: Abilify Maintena Intramuscular Prefilled Syringe 300 MG - Inject 300mg intramuscularly one time a day starting on the 1st and ending on the 1st every month related to schizophrenia and bipolar disorder.
Review of the clinical record indicated Resident R54 was admitted to the facility as stated above without a diagnosis of schizophrenia (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior leading to a faulty perception inappropriate action and feelings, withdrawal from reality and personal relationships into fantasy and delusion) Bipolar (having or relating to two poles or extremities).
Review of clinical information diagnosis sheet indicated resident R54 was given a diagnoses of schizophrenia and bipolar the month after admission.
Review of Resident R54 clinical record failed to include any diagnosis of schizophrenia or bipolar prior to admission.
During an interview on 6/9/23, at 12:36 p.m. Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility was unable to provide clinical information for Resident R54 prior to admit that showed a diagnosis of schizophrenia or bipolar and confirmed that ability was ordered for schizophrenia / bipolar but the facility couldn't not find a previous diagnosis of the diseases prior to the one given by the facility and that the facility failed to provide a diagnosis for an anti-psychotropic medication.
28 Pa. Code: 211.9(a)Pharmacy services.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on review of facility policy, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for three out of eight personnel files (N...
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Based on review of facility policy, personnel files and staff interviews it was determined that the facility failed to complete annual performance evaluations for three out of eight personnel files (Nurse Aide Employee E5, Nurse Aide Employee E6, and Nurse Aide Employee E7).
Findings include:
The facility Annual nurse aide evaluation document (no date), indicated that the evaluation is meant to judge performance at work and to help improve skills and techniques.
Review of Nurse aide Employee E5's personnel record indicated she was hired on 10/7/13. Review of Nurse aide Employee E5's personnel record did not include an annual performance evaluation for the year 2022.
Review of Nurse aide Employee E6 personnel record indicated he was hired on 6/20/16. Review of Nurse aide Employee E6's personnel record did not include an annual performance evaluation for the year 2022.
Review of Nurse aide Employee E7 personnel record indicated she was hired on 2/24/99. Review of Nurse aide Employee E7's personnel record did not include an annual performance evaluation for the year 2022.
During an interview on 6/07/23, at 1:05 p.m. the Nursing Home Administrator (NHA) stated that the facility did not have annual performance evaluations for the Nurse aide Employee E5, Nurse aide Employee E6, and Nurse aide Employee E7.
During an interview on 6/09/23, at 9:07 a.m. the Director of Human Recourses Employee E8 confirmed that the facility failed to complete annual performance evaluations for Nurse aide Employee E5, Nurse aide Employee E6, and Nurse aide Employee E7.
28 Pa Code: 201.20 (a)(b)(c)(d) Staff development.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected multiple residents
Based on review of facility documentation and staff interview it was determined that the facility failed to employ qualified staff to oversee the kitchen for six out of 12 months (January of 2023 to J...
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Based on review of facility documentation and staff interview it was determined that the facility failed to employ qualified staff to oversee the kitchen for six out of 12 months (January of 2023 to June of 2023).
Findings include:
Review of job description indicated that dietary manager indicated: Be a graduate of an accredited course in dieticians training approved by the American Dietetic Association.
During an interview on 6/7/23, at 2:13 p.m. Food Service Director Employee E11 indicated that he did not have the required certification for the Food Service Director job.
During an interview on 6/8/23, at 10:50 a.m. Corporate Consultant RD (Registered Dietitian) Employee E12 and they are not they do not supervise the dietary manager for certification course work. The facility provided documentation for dietary manager certification course work dated 6/5/23, but could not provide any other documentation.
During an interview on 6/8/23, at 10:55 a.m. Corporate Consultant RD Employee E12 confirmed that the facility failed to have a dietary manager who has current certification from the American Dietetic Association and did not have qualified staff for the kitchen.
28 Pa. Code: 211.16cDietary services.
28 Pa. Code: 201.18e(1)(6)Management.
Jan 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 F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and staff interview, it was determined the facility failed to make ce...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and staff interview, it was determined the facility failed to make certain that the representative of a cognitively impaired resident was fully informed of the resident's rights for one of three residents reviewed (Closed Record Resident CR1)
Finding include:
The facility policy Competency reviewed 5/17/22, revealed that In the case of a resident who has not been adjudged incompetent under state court, any legal surrogate designated in accordance with state law may exercise the resident's rights to the extent provided by state law. A resident may delegate decision making to specific persons, or the resident and family may have agreed among themselves on a decision-making process. The facility will respect the residents wishes and follow that process.
A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE]. The
Minimum Data Set (MDS- a periodic review of care needs) dated 11/13/22, included diagnoses of fracture of the left femur and dementia.
Review of the MDS section C0100: Cognitive Decision Making indicated that Resident CR1 suffered from moderate cognitive impairment.
Review of the clinical records dated 12/13/22, revealed that Resident CR1 signed the Notice Of Medicare Non-Coverage (NOMNC- form notifying a Medicare beneficiary payment for services is going to end) form and elected to give up rights to an appeal for services.
During an interview on 1/25/23, at 3:22 p.m., Licensed Practical Nurse Assessment Coordinator (LPNAC) and the Nursing Home Administrator, confirmed that Resident CR1 who suffers from moderate cognitive impairment, signed the NOMNC form on 12/13/22. During this interview, LPNAC Employee E2 confirmed that Resident CR1 was likely incapable of understanding his/her rights to appeal for Medicare covered services or another payment status and that the facility failed to contact Resident CR1's resident representative to discuss Resident CR1's rights.
28 Pa. Code 201.29(a)(l)(2) 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 F0745
(Tag F0745)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and staff interviews, it was determined that the facility failed to m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and staff interviews, it was determined that the facility failed to make certain that transportation was arranged for an outside medical appointment in a timely manner for one of three residents reviewed (Closed Record Resident CR1)
Findings include:
The facility policy Transfer to an appointment outside the Facility, reviewed 5/17/22, states the facility will: arrange for transportation as appropriate; notify the responsible party of the appointment; documentation should be entered in the nursing note section of the arrangements for the appointment/consultation outside the facility or of any difficulties in arranging the appointment.
A review of the clinical record revealed that Closed Record Resident CR1 was admitted to the facility on [DATE]. The Minimum Data Set (MDS- a periodic review of care needs) dated 11/13/22, included diagnoses of fracture of the left femur and dementia.
Review of the physician orders dated 11/10/22, indicated that resident Closed Record Resident CR1 was to follow up with the physicians office within one week.
Review the clinical record indicates resident Closed Record Resident CR1 was not seen by the physician until 12/1/22, (20 days later).
During a telephone interview on 1/25/22, at 12:33 p.m., the facility appointment scheduler Employee E1, reported that Closed Record Resident CR1 was seen by the physician on 12/1/22, twenty days after being admitted to the facility. Employee E1 confirmed that she did not have any documentation associated with the delay of the appointment.
During a telephone interview on 1/25/22 at 1:04 p.m. with the physicians' Senior Practice Manager, it was revealed that on 11/16/22, they had spoken with the facility and offered an earlier appointment, but the facility unable to secure transportation, had declined the appointment and scheduled the appointment for 12/1/22.
There was no documented evidence that the facility made attempts to secure transportation for the follow up appointment in a timely manner.
During an interview on 1/25/23, at 2:08 p.m. the Nursing Home Administrator confirmed the facility failed to provide evidence attempts were made to secure Closed Record Resident CR1 ' s follow-up appointment in a timely manner.
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.16(a) Social 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
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide written notice of a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide written notice of a facility initiated transfer in a timely manner to the resident and resident representative for one out of three closed resident records (Closed Resident Record CR1).
Findings include:
The facility Transfer and discharge notice policy dated 8/2016, last reviewed on 5/17/22, indicated that before a facility transfers or discharges a resident, the facility will give a notice of transfer. Written notice will include specific information, such as a record of the reason in the clinical record, effective date of discharge, the location to which the resident was transferred, a statement that the resident has the right to appeal the action, how to notify the ombudsman, a brief description of significant findings and events of the residents stay, timely notification of the next of kin, and if the transfer is due to an emergency this information will be recorded within 48 hours.
The facility Bed-hold policy and procedure policy dated 8/2016, last reviewed on 5/17/22, indicated that the vacant bed will be held while a resident is in the hospital. Medicaid pays for 15 days. If the hospitalization leave exceeds the number of days indicated, the resident will be readmitted immediately upon the first available bed if the resident is still eligible for Medicaid nursing services. Upon discharge from the facility, the Social services Department will contact by telephone and in writing the resident or responsible party to inform them that the resident was discharged to the hospital and of the 15-day bed-hold. The caller will inform the family to expect the Bed-hold letter and reservation request within a few days. The Bed-hold letter and reservation must be mailed on the date the resident was discharged to the hospital.
Review of Closed Resident Record CR1's admission record indicated she was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), lymphedema (blockage in the lymphatic system causing swelling to legs or arms), and hypertension (a condition impacting blood circulation through the heart related to poor pressure).
Review of Closed Resident Record CR1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 11/17/22, indicated that the diagnoses were the most recent upon review.
Review of Closed Resident Record CR1's nurse progress note dated 11/22/22, indicated that Closed Resident Record CR1's stated she was not feeling well. Vitals were taken, pulse ox (Pulse oximetry-test of oxygen level in the blood) was 65% on five liters of oxygen, Pulse 107, she felt cold, appeared, pale complexion. CRNP was called and order to send to hospital.
Review of Closed Resident Record CR1's physician orders dated 11/22/22, indicated ok to send to hospital to evaluate and treat for shortness of breath.
Review of Closed Resident Record CR1's nurse notes, physician notes and clinical record did not include the following: notice to family or resident about the facility bed-hold policy, documentation referring to communications with family about transfer/discharge notice and bed-hold days left, documentation indicating that a transfer/discharge notice was sent to the family, documentation indicating a review of transfer/discharge rights with the resident.
During an interview on 12/16/22, at 11:38 a.m. Licensed Practical Nurse (LPN) Employee E1 stated that staff send the resident facesheet (document showing admission, contact, and diagnoses information), POLST, med review list, diagnoses, must also send transfer to hospital form and bed-hold policy form when a resident is sent to the hospital. She stated that the information is on the SBAR form (Status, Background, Assessment, Recommendation) and it must be completed, and that information is given to EMT. She stated that staff discuss with the EMT information about the resident's baseline health status before they leave.
During an interview on 12/16/22, at 2:09 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide written notice of a facility initiated transfer in a timely manner to the resident and resident representative for Closed Resident Record CR1 as required.
28 Pa. Code 201.14(a) Responsibility of licensee
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy within 24 hours of transfer to the hospital for two out of three closed resident record (Closed Resident Record CR1 and CR2).
Findings include:
The facility Transfer and discharge notice policy dated 8/2016, last reviewed on 5/17/22, indicated that before a facility transfers or discharges a resident, the facility will give a notice of transfer. Written notice will include specific information, such as a record of the reason in the clinical record, effective date of discharge, the location to which the resident was transferred, a statement that the resident has the right to appeal the action, how to notify the ombudsman, a brief description of significant findings and events of the residents stay, timely notification of the next of kin, and if the transfer is due to an emergency this information will be recorded within 48 hours.
The facility Bed-hold policy and procedure policy dated 8/2016, last reviewed on 5/17/22, indicated that the vacant bed will be held while a resident is in the hospital. Medicaid pays for 15 days. If the hospitalization leave exceeds the number of days indicated, the resident will be readmitted immediately upon the first available bed if the resident is still eligible for Medicaid nursing services. Upon discharge from the facility, the Social services Department will contact by telephone and in writing the resident or responsible party to inform them that the resident was discharged to the hospital and of the 15-day bed-hold. The caller will inform the family to expect the Bed-hold letter and reservation request within a few days. The Bed-hold letter and reservation must be mailed on the date the resident was discharged to the hospital.
The facility Admissions packet: section three, bed-hold guidelines policy dated 1/2020 and last reviewed on 5/17/22, indicated that before the facility transfers a resident to the hospital, the facility shall provide written notice to the resident or resident representative that specifies the duration of the State bed-hold policy, the reserve bed payment policy, and facility's policies regarding bed-hold periods. If the facility determines that a resident was transferred cannot return to the facility, the facility shall provide a discharge notice as required by law.
Review of Closed Resident Record CR1's admission record indicated she was admitted on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD-a disease characterized by persistent respiratory symptoms involving breathlessness, coughing, and obstructed airflow to the lungs), diabetes (metabolic disorder impacting organ function related to glucose levels in the human body), lymphedema (blockage in the lymphatic system causing swelling to legs or arms), and hypertension (a condition impacting blood circulation through the heart related to poor pressure).
Review of Closed Resident Record CR1's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 11/17/22, indicated that the diagnoses were the most recent upon review.
Review of Closed Resident Record CR1's nurse progress note dated 11/22/22, indicated that Closed Resident Record CR1's stated she was not feeling well. Vitals were taken, pulse ox (Pulse oximetry-test of oxygen level in the blood) was 65% on five liters of oxygen, Pulse 107, she felt cold, appeared, pale complexion. CRNP was called and order to send to hospital.
Review of Closed Resident Record CR1's physician orders dated 11/22/22, indicated ok to send to hospital to evaluate and treat for shortness of breath.
Review of Closed Resident Record CR1's nurse notes, physician notes and clinical record did not include the following: notice to family or resident about the facility bed-hold policy, documentation referring to communications with family about transfer/discharge notice and bed-hold days left, documentation indicating that a transfer/discharge notice was sent to the family, official documentation reviewing transfer/discharge rights with the resident.
Review of Closed Resident Record CR2's admission record indicated he was admitted on [DATE], with diagnoses that included cognitive communication deficit, alcohol dependence withdrawal, diabetes and hypertension.
Review of Closed Resident Record CR2's MDS assessment dated [DATE], indicated that the diagnoses were the most recent upon review.
Review of Closed Resident Record CR2's nurse progress note dated 12/7/22, indicated he requested to speak with Director of Nursing regarding right great toe. He stated that there was pain in his toe and he believed that it was related to his toe nail. Foot was assessed, observed with some tenderness noted with some edema present. Closed Resident Record CR2 requested to go out to the hospital despite waiting for treatment at the facility.
Review of Closed Resident Record CR2's physician order dated 12/7/22, indicated to send to the emergency room for evaluation.
Review of Closed Resident Record CR2's nurse notes, physician notes and clinical record did not include the following: notice to family or resident about the facility bed-hold policy and documentation referring to communications with family about resident bed-hold rights.
During an interview on 12/16/22, at 11:38 a.m. Licensed Practical Nurse (LPN) Employee E1 stated that staff send the resident facesheet (document showing admission, contact, and diagnoses information), POLST, med review list, diagnoses, must also send transfer to hospital form and bed-hold policy form when a resident is sent to the hospital. She stated that the information is on the SBAR form (Status, Background, Assessment, Recommendation) and it must be completed, and that information is given to EMT. She stated that staff discuss with the EMT information about the resident's baseline health status before they leave.
During an interview on 12/16/22, at 2:09 p.m. the Nursing Home Administrator (NHA) confirmed that the facility failed to provide the resident and/or resident representative with a written notice of the facility bed-hold policy within 24 hours of transfer to the hospital for Closed Resident Record CR1 and CR2 as required.
28 Pa. Code: 201.18(e)(1) Management.
28 Pa. Code: 201.29(f) Resident rights.
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?"
- "What safeguards are in place to prevent abuse and neglect?"
- "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: Federal abuse finding, 2 life-threatening violation(s), $173,281 in fines. Review inspection reports carefully.
- • 77 deficiencies on record, including 2 critical (life-threatening) violations. These warrant careful review before choosing this facility.
- • $173,281 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 has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Kadima Rehabilitation & Nursing At Harmony's CMS Rating?
CMS assigns KADIMA REHABILITATION & NURSING AT HARMONY an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Kadima Rehabilitation & Nursing At Harmony Staffed?
CMS rates KADIMA REHABILITATION & NURSING AT HARMONY's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 68%, which is 22 percentage points above the Pennsylvania average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Kadima Rehabilitation & Nursing At Harmony?
State health inspectors documented 77 deficiencies at KADIMA REHABILITATION & NURSING AT HARMONY during 2022 to 2025. These included: 2 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 74 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 Kadima Rehabilitation & Nursing At Harmony?
KADIMA REHABILITATION & NURSING AT HARMONY 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 KADIMA HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 115 certified beds and approximately 109 residents (about 95% occupancy), it is a mid-sized facility located in HARMONY, Pennsylvania.
How Does Kadima Rehabilitation & Nursing At Harmony Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, KADIMA REHABILITATION & NURSING AT HARMONY's overall rating (1 stars) is below the state average of 3.0, staff turnover (68%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Kadima Rehabilitation & Nursing At Harmony?
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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations, the substantiated abuse finding on record, and the facility's high staff turnover rate.
Is Kadima Rehabilitation & Nursing At Harmony Safe?
Based on CMS inspection data, KADIMA REHABILITATION & NURSING AT HARMONY has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 2 Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death). The facility has a 1-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 Kadima Rehabilitation & Nursing At Harmony Stick Around?
Staff turnover at KADIMA REHABILITATION & NURSING AT HARMONY is high. At 68%, the facility is 22 percentage points above the Pennsylvania average of 46%. 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 Kadima Rehabilitation & Nursing At Harmony Ever Fined?
KADIMA REHABILITATION & NURSING AT HARMONY has been fined $173,281 across 2 penalty actions. This is 5.0x the Pennsylvania average of $34,812. 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 Kadima Rehabilitation & Nursing At Harmony on Any Federal Watch List?
KADIMA REHABILITATION & NURSING AT HARMONY is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.