RICHLAND NURSING AND REHAB
For profit - Corporation
97 Beds
VALLEY WEST HEALTH
Data: November 2025
Trust Grade
40/100
#623 of 653 in PA
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Richland Nursing and Rehab has a Trust Grade of D, indicating below-average performance and some significant concerns. It ranks #623 out of 653 facilities in Pennsylvania, placing it in the bottom half of all state facilities, and #9 out of 9 in Cambria County, meaning there are no better local options available. The facility is showing an improving trend, with reported issues decreasing from 25 in 2024 to just 2 in 2025. Staffing is a weakness, with a poor rating of 0 out of 5 stars and a turnover rate of 49%, which is around the state average, suggesting staff may not be consistently available to provide quality care. While the facility has no fines on record, which is a positive aspect, there have been concerning incidents; for example, residents were not properly notified about their transfers to the hospital, and there were failures to clarify questionable physician orders for care, posing potential risks to residents' health. Overall, families should weigh these strengths and weaknesses carefully when considering this nursing home.
- Trust Score
- D
- In Pennsylvania
- #623/653
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ○ Average
- RN staffing data not reported for this facility.
- Violations ⚠ Watch
- 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
40/100
Bottom 5%
No red flags
25 → 2 violations
★☆☆☆☆
1.0
Overall Rating
☆☆☆☆☆
0.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 25 issues
2025: 2 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: 49%
Near Pennsylvania avg (46%)
Higher turnover may affect care consistency
Chain: VALLEY WEST HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 44 deficiencies on record
Aug 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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of facility policies, clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional sta...
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Based on review of facility policies, clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders for one of 4 residents reviewed (Resident 2).Findings include:The facility's policy regarding medication administration, dated November 21, 2024, revealed that medications were to be administered in accordance with written orders of the attending physician. A admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 10 2025, revealed that the resident was moderately cognitively impaired, sometimes understood, required extensive assistance for daily care needs, and had diagnoses that included acute respiratory failure, heart attack, stroke, myasthenia gravis (weakness of muscles) and dementia. Physician's orders for Resident 2, dated July 9, 2025, included an order for Rivastigmine (Exelon) Transdermal Patch (a medicated patch used to treat dementia) 24 Hour 13.3 MG/24HR. Apply 1 patch one time a day related to vascular dementia and remove per schedule. Resident 2's Medication Administration Record (MAR) for July 2025, indicated that staff administered Exelon transdermal patch on July 19, 2025, and July 20, 2025, as per order (Old patch removed when new patch applied).A late entry nursing note dated July 21, 2025, at 9:00 a.m. indicated that the facility was made aware that Resident 2 was found to have two medication patches on when he arrived at the hospital on July 21, 2025.Interview with Licensed Practical Nurse 1, on August 5, 2025, at 1:30 p.m. revealed that she administered the Exelon patch on July 20, 2025, at 8:00 a.m., and indicated that she always takes the old patch off, reviews and administers the resident's pills and then applies the new patch. She went on to say that she was surprised to be informed by administration that Resident 2 was found to have two Exelon patches on him when he arrived at the hospital on July 21, 2025. Interview with the Director of Nursing on August 5, 2025, at 1:44 p.m. revealed that she was notified by Senior Life Care Services (a company that provides assistance for elder adults) that the hospital found two medication patches on Resident 2 when he arrived at the hospital on July 21, 2025. The facility began an investigation regarding the patch administration. She went on to say that the clinical documentation and verbal interview from the staff member involved indicated that the medication administration was done correctly. However, she understands that mistakes are made and that the hospital would not make up the story. She remarked that it was obvious that her staff must not have removed the old patch prior to putting on a new one, and she should have.28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
Jan 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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen was provided as ordered by the physicia...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that oxygen was provided as ordered by the physician for one of four residents reviewed (Resident 3).
Findings include:
The facility's policy regarding oxygen use, dated May 8, 2024, indicated that the facility was to verify the physician's order and provide safe oxygen administration.
An admission Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 20, 2024, revealed that the resident was severely cognitively impaired and received oxygen. A care plan, dated November 27, 2024, revealed that Resident 3 was at risk for respiratory impairment related to congestive heart failure (CHF) and had a history of pneumonia. Physician's orders, dated November 30, 2024, included an order for the resident to receive oxygen at zero to four liters per minute (lpm) every shift to maintain an oxygen saturation (measurement of the percentage of oxygen-rich hemoglobin in arterial blood) of 90 percent or more.
Observations of Resident 3 on January 29, 2025, at 12:56 p.m. revealed that the resident had oxygen in use at 3 lpm via nasal cannula (tube that delivers oxygen through the nose). Resident 3 requested to use the bed pan. Nurse Aide 1 and Nurse Aide 2 removed Resident 3's oxygen and transferred her into bed using a full body mechanical lift but did not reapply her oxygen.
Resident 3 was confused and did not use her call bell when finished, she just yelled out that she wanted off the bed pan. She was provided care and repositioned in the bed at 1:33 p.m. by Nurse Aides 1 and 2. Resident 3 said that she was not comfortable and that her neck and chest did not feel right. Licensed Practical Nurse 3 got a pulse oximeter (measures the oxygen saturation of arterial blood) measurement at 2:04 p.m. with a reading of 87 percent.
Interview with Nurse Aide 1 at 2:04 p.m. confirmed that Resident 3's oxygen was not reapplied after she was transferred to the bed and it should have been. Interview with Nurse Aide 2 at 2:05 p.m. confirmed that Resident 3 did not have her oxygen reapplied, and that is why she got so upset and angry.
Interview with Director of Nursing on January 29, 2025, at 5:05 p.m. confirmed that Resident 3 should have been provided her oxygen therapy as ordered.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Dec 2024
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on review of facility policy and clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs...
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Based on review of facility policy and clinical record reviews, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 37 residents reviewed (Resident 2).
Findings include:
The facility's policy regarding call bells, dated November 21, 2024, revealed that the call bell should be within reach of the resident.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated November 6, 2024, indicated that the resident was understood and could understand, was cognitively impaired, and was dependent on staff for all care needs. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach.
Observations of Resident 2 on December 16, 2024, at 10:15 a.m. revealed that the resident was lying in bed and was asking for her call bell. The call bell was in her nightstand drawer and was not within her reach.
Interview with Nurse Aide 1 at that time revealed that Resident 2 could use her call bell and that it should have been placed within her reach.
Interview with Director of Nursing on December 16, 2024, at 3:20 p.m. confirmed that the call bell should have been within reach.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the resident and/or responsible party was notified about the facility's bed-hold pol...
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Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the resident and/or responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for three of 37 residents reviewed (Residents 9, 37, 43). This deficiency was cited as past noncompliance.
Findings include:
A nursing note for Resident 9, dated August 11, 2024, at 12:17 p.m., revealed that Resident 9 had a large emesis, had acute abdominal pain, and a history of bowel obstruction (partial or complete blockage of the small or large intestine). The physician was notified, and the resident was sent to the hospital for an evaluation. He was admitted with a urinary tract infection and small bowel obstruction. There was no documented evidence that Resident 9 and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfers to the hospital.
A nursing note for Resident 37, dated June 29, 2024, at 3:00 a.m. revealed that Resident 37 was found lying on his floor mat between the wall and bed. No injuries were noted, and he was transferred to the hospital and admitted with altered mental status. There was no documented evidence that Resident 37 and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital.
A nursing note for Resident 43, dated September 7, 2024, at 5:19 a.m. revealed that the resident had a fall and complained of the left hip pain. The physician was notified and wanted the resident sent to the hospital for an evaluation and was admitted . There was no documented evidence that Resident 43 and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfers to the hospital.
Interview with the Director of Nursing (DON) on December 18, 2024, at 12:50 p.m. confirmed that there was no documented evidence that a bed-hold notice was issued to the above residents and/or their responsible party at the time of the transfers to the hospital. The DON also revealed that the new Business Office Manager had identified this as a concern on September 9, 2024.
Following the identification on September 9, 2024, that they were not providing the bed-hold notices to the resident and/or the resident's representative when the resident was transferred to the hospital, the facility's corrective actions included:
The new Business Office Manager will review the transfers daily with the interdisciplinary team and will call any resident representative regarding transfers to notify them of the bed-hold policy and inform them that they will be receiving a written notice in the mail.
Audits were started on all residents that were transferred to the hospital.
Utilization of a binder showing the date the bed-hold notification was made, and a copy of the returned, signed notification from the resident representative.
The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary.
Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F625 on September 18, 2024.
28 Pa. Code 201.25 Discharge Policy.
28 Pa. Code 201.29(a) Resident Rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set ...
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Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 37 residents reviewed (Residents 35, 36, 48, 60).
Findings include:
The Long Term Care Facility 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, revealed that Section N0300 was to indicate if the resident received any type of injection during the last seven days and Section H0100A was to indicate if the resident had a nephrostomy tube (a tube inserted through the skin into the kidney that carries urine from the kidney to the bladder).
Physician's orders for Resident 35, dated October 7, 2024, included an order for the resident's nephrostomy tube site be cleansed with normal saline solution and a dry dressing applied daily. A nursing note, dated November 10, 2024, revealed that the resident had a nephrostomy catheter.
Treatment Administration Records (TAR's) for Resident 35, dated November 2024, revealed that staff cleaned the resident's nephrostomy site with normal saline solution and applied a dry dressing daily from November 1 to 30, 2024. A review of the Medication Administration Records (MAR's), dated November 2024, revealed no documented evidence that Resident 35 received any injections. However, Section N0300 of Resident 35's quarterly MDS assessment, dated November 13, 2024, was coded to indicate that the resident received injections on three days during the seven-day assessment period and Section H0100A was not coded to indicate that Resident 35 had a nephrostomy tube.
The RAI manual, dated October 2024, revealed that Section N0350A was to indicate that the resident received an insulin injection during the last seven days and Section N0415F (Antibiotic - medications) was to indicate any medications the resident was taking by pharmacological classification, during the last seven days, or since admission/entry or reentry if less than seven days.
Physician's orders for Resident 36, dated November 16, 2024, included orders for the resident to receive 25 units of Novolog (rapid acting insulin) subcutaneously (beneath the skin) three times a day for diabetes.
Medication Administration Record's (MAR's) for Resident 36, dated November 2024, revealed that the resident received Novolog insulin as ordered from November 16 to November 30, 2024. A review of the MAR, dated November 2024, revealed no documented evidence that Resident 36 received an antibiotic during the review period. Section N050A of Resident 36's quarterly MDS assessment, dated November 21, 2024, was not coded to indicate that the resident received insulin injections during the seven days of the assessment period and Section N0415F was coded to indicate that Resident 36 received an antibiotic during the seven days of the assessment period.
Physician's orders for Resident 48, dated October 24, 2024, included orders for 2 percent Mupirocin (antibiotic) ointment be applied daily to the resident's diabetic ulcer on his right foot. Treatment Administration Records for Resident 48, dated October and November 2024, revealed that staff applied Mupirocin to the resident's diabetic ulcer on October 27 and 28, and November 1 and 2, 2024.
However, Section N0415F of Resident 48's quarterly MDS assessment, dated November 2, 2024, was coded to indicate that the resident did not receive an antibiotic during the seven days of the assessment period.
Interview with the Assistant Director of Nursing on December 18, 2024, at 8:42 a.m. confirmed that the MDS assessments for Residents 35, 36 and 48 were coded incorrectly.
The RAI User's Manual, dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0415A1 was to be checked if the resident was taking an antipsychotic medication (drugs that treat psychotic disorders) during the last seven days or since admission/entry or reentry if less than seven days, and Section N0450A was to be coded zero (0) No if antipsychotics were not received, and coded (1) Yes if the resident received an antipsychotic medication since admission/entry or reentry, or since the prior MDS assessment, whichever was more recent.
Physician's orders for Resident 60, dated September 27, 2024, included an order for the resident to receive one five milligram (mg) tablet of Abilify (an antipsychotic medication) daily for major depressive disorder (a serious mental illness that affects how people feel, think, and act).
Medication Administration Records (MARs) for Resident 60, dated November 2024, revealed that staff administered Abilify to the resident November 1 through 15, 2024.
A quarterly MDS assessment for Resident 60, dated November 15, 2024, revealed that Section N0415A1 indicated that the resident received an antipsychotic medication the last seven days during the assessment period. However, Section N0450A was coded as (0) No, indicating that the resident did not receive antipsychotic medication since admission/entry or re-entry, or since the prior MDS assessment.
Interview with Registered Nurse Assessment Coordinator 2 (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on December 18, 2024, at 3:35 p.m. confirmed that Section N0450A was coded inaccurately for Resident 60, who consistently received antipsychotic medication.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care n...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for four of 37 residents reviewed (Residents 28, 33, 39, 68).
Findings include:
The facility's policy regarding care plans, dated November 21, 2024, indicated that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team must review and update the care plan when there has been a significant change in the resident's condition; when the desired outcome is not met; when the resident has been readmitted to the facility from a hospital stay; and at least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs).
A quarterly MDS assessment for Resident 28, dated September 26, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, required assistance with care needs, and had a diagnosis of end-stage kidney disease. A care plan for Resident 28, dated September 29, 2024, indicated that the resident was on dialysis and was to be assessed to ensure patency for his fistula (a surgically-created connection between an artery and a vein to provide access for dialysis) by feeling for a thrill (vibration or buzzing sensation that indicates blood is flowing through a fistula) or listening for a bruit (a whooshing sound that indicates high-pressure blood flow through a fistula).
Physician's orders for Resident 28, dated September 29, 2024, included an order for the resident to receive dialysis on Monday, Wednesday, and Friday.
Observations of Resident 28 on December 18, 2024, at 2:02 p.m. revealed a Central Venous Catheter (a type of vascular access that allows blood to travel to and from a dialysis machine) in the left side of his chest, and that the resident did not have a fistula for dialysis.
There was no documented evidence in Resident 28's clinical record to indicate that the care plan was updated to include the care and treatment of a central venous catheter for dialysis.
Interview with the Director of Nursing on December 18, 2024, at 2:28 p.m. confirmed that Resident 28's care plan was not updated to include the care and treatment of a central venous catheter for dialysis and should have been.
A quarterly MDS assessment for Resident 33, dated October 25, 2024, revealed that the resident was cognitively intact, was understood and able to understand others, was dependent on staff with care needs, and had a diagnosis of multi-drug resistant organisms. A care plan for Resident 33, dated October 27, 2024, indicated that the resident was on contact precautions (an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use) secondary to ESBL - Escherichia coli (ESBL - E. coli) (a multi-drug resistant bacteria) in her urine causing a urinary tract infection (UTI).
Physician's orders for Resident 33, dated November 2, 2024, included an order that the resident was no longer on contact precautions for ESBL- E. coli.
Observations during the initial tour on December 16, 2024, at 10:35 a.m. revealed that Resident 33 did not have signage on the door to indicate that contact precautions were in place. As of December 17, 2024, there was no documented evidence that Resident 33's care plan was revised/updated to reflect that her UTI due to ESBL- E. coli was resolved, and that the resident was no longer on contact precautions.
Interview with the Assistant Director of Nursing/Infection Preventionist on December 18, 2024, at 8:24 a.m. confirmed that Resident 33's UTI due to ESBL - E. coli was resolved, and the resident was not on contact precautions, and the care plans for the contact precautions and UTI due to ESBL - E. coli should have been resolved and they were not.
A quarterly MDS assessment for Resident 39, dated November 14, 2024, revealed that the resident was cognitively impaired, was understood and able to understand others, required assistance with care needs, and had no pressure injuries (a localized area of skin damage caused by prolonged pressure on the skin). A care plan for Resident 39, dated August 29, 2024, indicated that the resident was on Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities) secondary to a chronic wound. A care plan for Resident 39, dated September 5, 2024, indicated that the resident had actual skin breakdown related to a Stage 2 pressure ulcer (pressure wound with superficial skin loss) to her left elbow and left hip. Physician's orders for Resident 39, dated August 29, 2024, indicated that the resident was on EBP related to a chronic wound.
A wound consult note from Healing Hands Certified Registered Nurse Practitioner (CRNP - a registered nurse who has additional education and training allowing them to work under a broader scope of practice), dated September 3, 2024, indicated that Resident 39's Stage 2 pressure areas to her left elbow and left hip were resolved.
Observations during the initial tour on December 16, 2024, at 10:00 a.m. revealed that Resident 39 did not have signage on the door to indicate that EBP were in place. As of December 17, 2024, there was no documented evidence that Resident 39's care plan was revised/updated to reflect that her pressure ulcers were resolved, and the resident was not on EBP.
Interview with the Assistant Director of Nursing/Infection Preventionist on December 17, 2024, at 2:39 p.m. confirmed that Resident 39's pressure ulcers were resolved, the resident was not on EBP, and the care plans for the EBP and the actual skin impairments should have been resolved and they were not.
A quarterly MDS assessment for Resident 68, dated November 2, 2024, revealed that the resident was sometimes understood, could sometimes understand others, and had no pressure injuries. A care plan for the resident, dated May 1, 2024, revealed that the resident was at risk for alteration in skin integrity related to impaired mobility.
A nursing note for Resident 68, dated December 2, 2024, revealed that the nurse aide reported to the licensed practical nurse that a red open area was noted to the resident's left outer ankle, measuring one centimeter (cm) by two cm by 0.5 cm. The area was an old wound that reopened.
A CRNP note for Resident 68, dated December 11, 2024, revealed that she had been consulted to follow the resident for a reopened Stage 3 pressure injury (damage extends through all layers of the skin and into the underlying fatty tissue, but does not expose muscle, tendon, or bone) to left lateral malleolus (the bone on the outside of the ankle joint, at the end of the fibula bone). The area had been resolved since October 8, 2024.
However, as of December 19, 2024, there was no documented evidence that Resident 68's care plan was revised/updated to include the reopened Stage 3 pressure injury to the resident's left lateral malleolus.
Interview with the Director of Nursing on December 19, 2024, at 10:26 a.m. confirmed that Resident 68's care plan was not revised/updated to include the reopened Stage 3 pressure injury to the resident's left lateral malleolus.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to apply dressings to pressure ulcers as ordered by the physician for one of ...
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Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to apply dressings to pressure ulcers as ordered by the physician for one of 37 residents reviewed (Resident 19).
Findings include:
A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated December 3, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included Stage 4 Pressure Ulcer (damage extends through all layers of skin, reaching the underlying muscle, tendon, or bone, often with exposed tissue) to his left heel, and a non-stageable pressure ulcer (unable to determine the depth of the wound) to another site. A care plan for the resident, dated November 6, 2024, revealed that the resident had an actual skin breakdown to his left great toe and staff was to administer the treatment per the physician's orders.
Physician's orders for Resident 19, dated December 13, 2024, included an order for staff to cleanse the resident's left great toe with Acetic Acid 0.25 percent (a colorless, acidic liquid with a strong vinegar-like odor used to prevent the growth of bacteria), then apply medical grade honey (used in healing wounds) then apply Calcium Alginate (a highly absorptive, non-occlusive dressing) to the base of the wound, then secure with gauze and paper tape daily.
Observations of Resident 19's wound care to his left toe on December 16, 2024, at 12:51 p.m. revealed that Licensed Practical Nurse 4 washed her hands then placed the Acetic Acid 0.25 percent into two different cups and then applied clean gloves. She removed the old bandage from the resident's left great toe, placed a 4 x 4 gauze pad into the Acetic Acid 0.25 percent, and then removed the 4 x 4 gauze and cleansed the resident's left great toe. She then removed her gloves and washed her hands. She donned new gloves and placed a 2 x 2 dressing in the other cup containing the Acetic Acid 0.25 percent. She removed the 2 x 2 dressing from the cup containing the Acetic Acid 0.25 percent and applied the dressing to the wound on the resident's left great toe. She then placed a dry gauze over the 2 x 2 soaked Acetic Acid 0.25 percent on the resident's left great toe and then secured the dressing with paper tape.
Interview with Licensed Practical Nurse 4 on December 16, 2024, at 1:18 p.m. confirmed that she did not apply the medical grade honey and Calcium Alginate as ordered by the physician to Resident 19's left great toe wound.
Interview with the Assistant Director of Nursing/Infection Control Preventionist on December 16, 2024, at 2:00 p.m. confirmed that Resident 19's wound treatment to his left great toe was not completed as ordered by the physician.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an intravenous line (a medical technique that administers fluid...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an intravenous line (a medical technique that administers fluids, medications, and nutrients directly into a person's vein) was flushed in accordance with facility policy for one of 37 residents reviewed (Resident 10).
Findings include:
The facility's policy regarding flushing midline (a thin, flexible tube that is inserted into a vein in the upper arm to deliver intravenous fluids or medicine) and central line (a long, flexible tube that is inserted into a large vein to provide access to the heart) intravenous catheters, dated November 21, 2024, revealed that midline and central line intravenous catheters will be flushed to maintain patency, to prevent mixing of incompatible medications and solutions, and to ensure entire dose of solution or medication is administered into the venous system. Flush catheters at regular intervals to maintain patency and before and after following administration of medication. Use the SASH method (saline, administer medication, saline, heparin) for intermittent treatments.
Physician's orders for Resident 10, dated November 14, 2024, included an order for staff to flush the peripherally inserted central catheter (PICC - a long, flexible tube that is inserted into a vein in the arm, leg, or neck and threaded into a large vein near the heart) with 10 milliliters (ml) of 0.9 percent Normal Saline (a mixture of sodium chloride (salt) and water) every shift for intravenous line patency.
Physician's orders for Resident 10, dated November 14, 2024, included an order for staff to administer one gram (gm) of Ertapenem Sodium (used alone or in combination with other antibiotics to treat infections caused by bacteria in many different parts of the body) intravenously one time a day for urinary tract infection (UTI).
Resident 10's Medication Administration Records (MAR's) for November 2024 revealed that staff administered the one gm of Ertapenem Sodium every day at 9:00 a.m. from November 15 through 24, 2024. There was no documented evidence that the resident's intravenous catheter was flushed before or after medication administration per the facility's policy on those dates.
Interview with the Director of Nursing and Assistant Director of Nursing on December 18, 2024, at 11:15 a.m. confirmed that there was no documented evidence that Resident 10's IV catheter was flushed according to the facility's policy.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose co...
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Based on review of manufacturer's instructions, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to label multi-dose containers of inhalers with the date they were opened in one of two medication carts reviewed (B-wing med cart), failed to discard a discontinued insulin pen in one of two medication carts reviewed (B-wing med cart), failed to obtain temperatures for the medication room refrigerator on the night shift, and failed to properly secure medications in the medication cart (C-wing med cart).
Findings include:
Manufacturer's directions for use of Fluticasone-Salmeterol (an inhaled medication used to help open the airways and make it easier to breathe), dated April 2008, indicated to discard Fluticasone-Salmeterol diskus one month after opening the foil tray or when the counter reads 0, whichever comes first. Write the Pouch opened and Use by dates on the label on top of the diskus. The Use by date is one month from date of opening the pouch.
Physician's orders for Resident 2, dated August 11, 2022, included an order for the resident to inhale one puff of Advair diskus (Fluticasone-Salmeterol) 100-50 micrograms (mcg) two times daily.
Observations of the B-wing medication cart on December 18, 2024, at 2:33 p.m. revealed that Resident 2 had a box, dated August 3, 2024, that contained an opened, undated Fluticasone-Salmeterol diskus. Observations at that time revealed a second undated bag for Resident 2 that contained an opened, undated Fluticasone-Salmeterol diskus.
Interview with Licensed Practical Nurse 5 at the time of observation confirmed that the opened containers of Resident 2's Fluticasone-Salmeterol diskus should have been labeled with the date they were opened and they were not.
Observations of the B-wing medication cart on December 18, 2024, at 2:33 p.m. revealed that Resident 63 had an insulin Lispro (Humalog) pen, dated November 11, 2024, that was in a bag labeled Novolog insulin with three other insulin pens labeled Novolog insulin. Review of Resident 63's clinical record revealed that the resident did not have a current order for insulin Lispro (Humalog).
Interview with Licensed Practical Nurse 5 at the time of observation confirmed that Resident 63 did not have a current order for insulin Lispro (Humalog) and that the insulin Lispro (Humalog) pen should have been discarded and it was not.
The facility's policy regarding medication labeling and storage, dated November 21, 2024, revealed that medications requiring refrigeration between 36 and 46 degrees Fahrenheit are kept in a refrigerator with a thermometer to allow daily temperature monitoring and documentation, and that medications should be properly secured in the medication cart at all times.
Observations in the medication room on December 17, 2024, at 9:38 a.m. revealed that the medication refrigerator contained seven different types of insulins, with a total of approximately 68 insulin pens, 15 flu pens, 11 morphine pens, one Rocephin (antibiotic) intravenous infusion, and one bottle of eye drops. Observations of the December 2024 medication temperature log sheet, located on the door of the medication refrigerator, revealed that from December 1-17 the refrigerator temperature was taken a total of six times: December 4, 5, 6, 10, 13 and 15.
Interview with Registered Nurse 6 on December 17, 2024, at 9:40 a.m. confirmed that the medications stored in the refrigerator required a temperature range between 36 and 46 degrees Fahrenheit, and that staff are to check it nightly and document the temperature on the log sheet, and they did not.
Observations of the C-wing medication cart on December 17, 2024, at 9:48 a.m. revealed that there were three loose medications found at the bottom of one medication drawer: one green oval; one round, bright orange; and one brown, oblong tablet.
Interview with Licensed Practical Nurse 7 on December 18, 2024, at 9:50 p.m. indicated that she cleans the medication drawers on a regular basis and was surprised that there were three loose pills found.
Interview with the Assistant Director Of Nursing on December 18, 2024, at 2:44 p.m. confirmed that multi-dose containers of inhalers should be labeled with the date they are opened, unused insulins should be discarded from the medication cart, the medication refrigerator required nightly documented temperature checks, and no loose medication tablets should be in the medication cart drawers.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(1) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plan of correction for the State Survey and Certification (Department of Health) survey ending January 11, 2024, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending December 19, 2024, identified repeated deficiencies related to quality of care/following physician's orders, treatment of pressure ulcers, medication storage and labeling, and following infection control practices.
The facility's plan of correction for a deficiency regarding quality of care/failure to follow physician's orders, cited during the survey ending January 11, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to maintain ongoing compliance with the regulation regarding quality of care/following physician's orders.
The facility's plan of correction for a deficiency regarding treatment of pressure ulcers, cited during the survey ending January 11, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F686, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the treatment of pressure ulcers.
The facility's plan of correction for a deficiency regarding proper storage and/or labeling of medications, cited during the survey ending January 11, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storing and labeling of medications properly.
The facility's plan of correction for a deficiency regarding following infection control practices, cited during the survey ending January 11, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding following infection control practices.
Refer to F684, F686, F761, F880.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospita...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for six of 37 residents reviewed (Residents 9, 28, 36, 37, 43, 62).
Findings include:
A nursing note for Resident 9, dated August 11, 2024, at 12:17 p.m., revealed that the resident had a large emesis, had acute abdominal pain, and a history of bowel obstruction (partial or complete blockage of the small or large intestine). The physician was notified, and the resident was sent to the hospital for an evaluation. He was admitted with a urinary tract infection and small bowel obstruction. There was no documented evidence that a written notice of Resident 9's transfer to the hospital and reason for hospitalization was provided to the resident's representative.
A nursing note for Resident 28, dated October 22, 2024, at 8:06 p.m., revealed that the resident was transferred to the hospital and admitted with a heart attack. There was no documented evidence that a written notice of Resident 2's transfer to the hospital and reason for hospitalization was provided to the resident's representative.
A nursing note for Resident 36, dated November 10, 2024, at 4:46 p.m., revealed that the resident was transferred to the hospital and admitted with a urinary tract infection. There was no documented evidence that a written notice of Resident 36's transfer to the hospital was provided to the resident's representative.
A nursing note for Resident 37, dated June 29, 2024, at 3:00 a.m., revealed that the resident was transferred to the hospital and admitted with altered mental status. There was no documented evidence that a written notice of Resident 9's transfer to the hospital and reason for hospitalization was provided to the resident's representative.
A nursing note for Resident 43, dated September 7, 2024, at 5:19 a.m., revealed that the resident had a fall and complained of the left hip pain. The physician was notified and the resident was sent to the hospital for an evaluation and was admitted . There was no documented evidence that a written notice of Resident 43's transfer to the hospital and reason for hospitalization was provided to the resident's representative.
A nursing note for Resident 62, dated November 9, 2024, at 9:26 p.m., revealed that the resident was transferred to the hospital and admitted with a diagnosis of status epilepticus (long-acting multiple seizures). There was no documented evidence that a written notice of Resident 62's transfer to the hospital was provided to the resident's representative.
Interview with the Director of Nursing on December 18, 2024, at 10:33 a.m. confirmed that the facility did not provide a written notice to the above residents and/or their representative when the residents were transferred to the hospital and/or the reason for hospitalization.
28 Pa. Code 201.25 Discharge Policy.
28 Pa. Code 201.29(f)(g) Resident Rights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on review of the Pennsylvania's Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a questionable physician's order for t...
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Based on review of the Pennsylvania's Nurse Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a questionable physician's order for three of 37 residents reviewed (Residents 19, 63, 76).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.
Physician's orders for Resident 19, dated October 11, 2024, included an order for staff to flush the resident's feeding tube (a medical device that provides nutrition, fluids, and medication to people who are unable to eat or drink safely by mouth) with 50 milliliters (ml) of water before and after administering medications and flush with 5 ml of water between each medication administered.
A nutritional note for Resident 19, dated December 3, 2024, revealed that the resident was aware of his oral intake being improved. The resident made it known that he did not want the tube feeding to be restarted. He agreed to the use of oral supplementation if needed.
A progress note for Resident 19, dated December 11, 2024, revealed that a care plan meeting was held that date indicating that the resident's tube feeding was recently discontinued.
Interview with Licensed Practical Nurse 3 on December 18, 2024, at 9:10 a.m. revealed that Resident 19 still has the feeding tube in place, that she does not use it for administering his medications, and that she gives all of his medications by mouth.
Interview with Resident 19, 2024, at 9:25 a.m. revealed that he takes everything by mouth now and that they do not use the feeding tube to administer any feedings and/or medications. He indicated that he is hoping that they soon get rid of the feeding tube.
There was no documented evidence that Resident 19's physician was contacted to clarify how the resident's feeding tube was to be flushed, since he does not receive his medications by the feeding tube.
Interview with the Director of Nursing December 18, 2024, at 12:30 p.m. confirmed that there was no documented evidence that Resident 19's physician was contacted to clarify how the resident's feeding tube was to be flushed, since he does not receive his medications by the feeding tube.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 63, dated November 14, 2024, indicated that the resident was cognitively intact, could understand others and was understood, and had a diagnosis of diabetes.
Physician's orders for Resident 63, dated November 14, 2024, included an order for the resident to receive 14 units of insulin lispro (a fast-acting medication to help regulate blood sugar levels in persons with diabetes) at 8:00 a.m., 12:00 p.m., and 5:15 p.m.
Review of Resident 63's Medication Administration Record (MAR) for November and December 2024 revealed that the resident did not receive the 14 units of insulin lispro on November 14, 2024, at 5:15 p.m.; November 15, 2024, at 5:15 p.m.; November 20, 2024, at 8:00 a.m.; November 21, 2024, at 8:00 a.m.; November 22, 2024, at 8:00 a.m.; November 23 2024, at 8:00 a.m.; November 24, 2024, at 5:15 p.m.; November 25, 2024, at 8:00 a.m.; November 26, 2024, at 8:00 a.m.; November 29, 2024, at 8:00 a.m.; November 30, 2024, at 8:00 a.m.; and December 3, 2024, at 5:15 p.m.
Interview with Assistant Director of Nursing on December 19, 2024, at 11:11 a.m. confirmed that the insulin was not given to Resident 63 on the dates and times listed above, and that previously Resident 63 had orders to hold the insulin if the blood sugar was less than or equal to 150 mg/dl. The orders were recently changed by pharmacy and signed off by the site medical director and did not include holding the insulin. The new orders should have been clarified by the physician before holding the insulin.
A quarterly MDS assessment for Resident 76, dated December 6, 2024, indicated that the resident was cognitively intact and had diagnoses that included heart failure and hypotension (low blood pressure).
Physician's orders for Resident 76, dated November 18 and December 2, 2024, included orders for the resident to receive 5 milligrams (mg) of Midodrine (a medication used for low blood pressure) with meals three times on Mondays, Wednesdays, Fridays, and Sundays, and to be given if the resident's systolic blood pressure (pressure within heart when heart is pumping) was less than 90 mmHg and to hold if the resident's systolic blood pressure was greater than 120 mmHg or above.
Resident 76's Medication Administration Records (MAR's) for November and December 2024 indicated that the resident's blood pressure at 5:30 a.m. was 101/66 mmHg on November 24, 104/52 mmHg on November 25, and 114/76 mmHg on November 27; at 12:30 p.m. was 104/60 mmHg on December 9, 116/70 mmHg on December 4, 110/60 mmHg on December 9, and 116/64 mmHg on December 16; at 5:30 p.m. was 118/60 mmHg on November 20, 107/63 mmHg on November 25, 100/56 mmHg on November 27, 118/78 mmHg on December 4, and 110/74 mmHg on December 6, 2024.
However, according to the MAR's, staff administered Midodrine on these days when the medication order should have been clarified for what to do when the resident's systolic blood pressure was between 90 and 120 mmHg.
Interview with the Assistant Director of Nursing on December 18, 2024, at 2:39 p.m. confirmed that staff should have clarified the Midodrine order with the physician when the resident's systolic blood pressure was between 90 and 120 mmHg.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete neurological checks per protocol following a fall for one of 37 re...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete neurological checks per protocol following a fall for one of 37 residents reviewed (Resident 37) and failed to ensure that medications were provided as ordered by the physician for one of 37 residents reviewed (Resident 76).
Findings include:
The facility's examination and assessment policy, dated November 21, 2024, indicated that the purpose was to examine and assess the resident for any abnormalities in their health status, one way to do this was to use a neurological assessment flow sheet. The neurological assessment form indicated that neurological checks would be completed every 15 minutes for one hour, every hour for four hours, and every four hours for 19 hours.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 37, dated October 9, 2024, indicated that the resident was moderately cognitively impaired and had diagnoses that included peripheral vascular disease (a slow, progressive disorder of the blood vessels) and atrial fibrillation (an irregular heartbeat).
Nursing notes indicated that on June 28, 2024, at 3:30 a.m. Resident 37 was found lying on his floor mat between the wall and bed, assessments were done, and no injury was noted. Later that day the resident did not appear to be himself, spilling his pills all over himself, presenting with right-sided weakness and pain, mouth drooping, and the inability to tell staff where he was. A neurological assessment form was started as per the facility protocol and the resident examination and assessment policy.
A review of the neurological assessment form check list for Resident 37's June 28, 2024, fall revealed that the assessments were not completed as per the facility's protocol.
The facility's medication administration policy, dated November 21, 2024, indicated that medications should be given as per physicians orders.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 76, dated December 6, 2024, indicated that the resident was cognitively intact and had diagnoses that included heart failure and hypotension (low blood pressure).
Physician's orders for Resident 76, dated November 9 and December 2, 2024, included orders for the resident to receive 5 milligrams (mg) of Midodrine (a medication used for low blood pressure) with meals three times on Tuesdays, Thursdays and Saturdays and to hold if the resident's systolic blood pressure (pressure within the heart when the heart is pumping) was 120 millimeters of mercury (mmHg) or above.
Resident 76's Medication Administration Records (MAR's) for November and December 2024 indicated that the resident's blood pressure at 5:30 a.m. was 141/78 mmHg on November 28 and 122/70 mmHg on November 30; at 12:30 p.m. was 138/76 mmHg on December 3, 130/74 mmHg on December 7, and 136/88 mmHg on December 12; and at 5:30 p.m. was 126/58 mmHg on November 19, 2024. However, according to the MAR's, staff administered Midodrine on these days when the medication should have been held.
Interview with the Assistant Director of Nursing on December 18, 2024, at 2:39 p.m. confirmed that staff should have completed the neurological assessments for Resident 37 as per facility protocol, and the Midodrine should have been held for Resident 76 when the resident's systolic blood pressure was more than 120 mmHg.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on review of clinical records and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs w...
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Based on review of clinical records and facility investigations, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of 37 residents reviewed (Residents 36, 59). This deficiency was cited as past non-compliance.
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 36, dated November 21, 2024, revealed that the resident was cognitively intact, was understood and understands, required assistance with care needs, had occasional pain, received pain medication routinely and as needed, and received an opioid (a controlled pain medication).
Physician's orders for Resident 36, dated April 16, 2024, included and order for the resident to receive 10 milligrams (mg) of Oxycodone every six hours as needed for pain related to chronic pain syndrome.
An investigation by the facility, dated June 7, 2024, revealed that during audits for drug diversion it was noted that 60 tablets of Oxycodone 10 mg were unable to be accounted for. There were two cards containing 60 tablets each delivered on May 23, 2024, and only one of those cards could be located.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated October 26, 2024, revealed that the resident was moderately cognitively impaired, was understood and understands, required assistance with care needs, had continuous pain, received pain medication three times a day, and received an opioid (a controlled pain medication).
Physician's orders for Resident 59, dated March 26, 2024, included and order for the resident to receive 5 milligrams (mg) of Oxycodone every eight hours for pain related to polyneuropathy (disease of the nervous system causing pain, numbness and weakness).
An investigation by the facility, dated May 26, 2024, revealed that during audits for drug diversion it was noted that 60 tablets of Oxycodone 5 mg were unable to be accounted for. There were two cards containing a total of 88 tablets delivered on May 8, 2024, and only one of those cards could be located.
Interview with the Director of Nursing on December 17, 2024, at 12:24 p.m. confirmed that the facility was unable to locate the missing cards of pain medications for Residents 36 and 59.
Following the identification of missing narcotics, the facility's corrective actions included:
The facility was unable to identify a perpetrator. Drug testing was completed on licensed practical nurses that were assigned to the B wing medication cart during the time of the missing narcotics.
New narcotic accountability forms were created and placed in the accountability binders for each medication cart.
Education was completed on the new narcotic accountability sheets that were placed in the narcotic accountability binders.
Narcotic accountability audits would be completed weekly for three weeks , then monthly for two months, or until compliance was met.
A review of the facility's corrective actions revealed that they were in compliance with F755 on June 24, 2024.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to mainta...
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Based on review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of 37 residents reviewed (Residents 19, 62, 76).
Findings include:
CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (MDRO) transmission was common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.
The facility's policy regarding EBP, dated November 21, 2024, indicated that EBP are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room); PPE is changed before caring for another resident, and face protection may be used if there is also a risk of splash or spray. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing; bathing/showering; transferring; providing hygiene, changing linens; changing briefs or assisting with toileting; device care, and wound care (any skin opening requiring a dressing). EBP's are indicated for residents with wounds and/or indwelling medical devices. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.
A significant change in status Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 19, dated December 3, 2024, revealed that the resident was understood, could understand others, had a diagnosis which included Stage 4 Pressure Ulcer (damage extends through all layers of skin, reaching the underlying muscle, tendon, or bone, often with exposed tissue) to his left heel, and a non-stageable pressure ulcer (unable to determine the depth of the wound) to another site. A care plan for the resident, dated November 6, 2024, revealed that the resident had an actual skin breakdown to his left great toe. A care plan, dated September 22, 2024, revealed that the resident was on EBP, and staff was to use gown and gloves during high contact activities (e.g., dressing, hygiene, toileting, transferring, bathing/ showering, changing linens, device care, wound care, therapy).
Physician's orders for Resident 19, dated October 29, 2024, included an order for the resident to be on EBPs.
Observations of Resident 19's wound care to his left heel and left great toe on December 16, 2024, at 12:51 p.m. revealed that Licensed Practical Nurse 4 washed her hands then placed clean gloves on; however, she did not apply a gown. She then performed the wound treatment to the resident's left heel and left great toe.
Interview with Licensed Practical Nurse 4 on December 16, 2024, at 1:18 p.m. confirmed that she did not apply a gown prior to performing Resident 19's wound treatment. She indicated that the resident was no longer on EBP because his feeding tube was discontinued.
Interview with the Assistant Director of Nursing/Infection Control Preventionist on December 16, 2024, at 2:00 p.m. confirmed that Licensed Practical Nurse 4 should have applied a gown prior to performing Resident 19's wound treatment.
The facility's policy regarding wound care and hand washing/hand hygiene, dated November 21, 2024, revealed that staff were to provide wound care in a manner to decrease potential for infection and/or cross-contamination. In addition, gloves should be removed and hand hygiene done prior to moving from a dirty to clean task.
A significant change in status Minimum Data Set (MDS) assessment for Resident 62, dated November 24, 2024, indicated that the resident was cognitively intact, required extensive assistance from staff for care tasks, had diagnoses that included chronic obstructive pulmonary disease and stroke, and had an alteration of skin integrity related to immobility and incontinence. Physician's orders, dated December 9, 2024, included an order to cleanse the bilateral buttocks twice a day with soap and water, apply Dermagran (a vitamin enriched wound dressing), and cover with an abdominal pad.
Observations of Resident 62's wound care on December 17, 2024, at 10:26 a.m. revealed that Licensed Practical Nurse 4 washed her hands and put on gloves prior to cleaning the area on the resident's right and left buttocks with a wash cloth and soap and water, she then patted the area dry with a dry wash cloth, removed her gloves, washed her hands, donned new gloves, applied Dermagran to her gloved hands, rubbed her hands together, applied the Dermagran to the bilateral buttocks area, and covered the area with an abdominal pad. Licensed Practical Nurse 4 then turned off the resident's oxygen, adjusted her pillow, and covered her up with the sheet. She then removed her gloves and sanitized her hands. Licensed Practical Nurse 4 did not remove her gloves and wash her hands after providing wound care and before turning off the oxygen and adjusting the resident's pillow and sheets.
Interview with Licensed Practical Nurse 4 on December 17, 2024, at 10:38 a.m. confirmed that she did not remove her gloves and wash her hands after Resident 62's wound care and prior to turning off the oxygen and adjusting the resident's pillow and sheets.
Interview with the Assistant Director of Nursing on December 17, 2024, at 12:38 p.m. confirmed that Licensed Practical Nurse 4 should have removed her gloves and washed her hands after Resident 62's wound care, and prior to turning off the oxygen and adjusting the resident's pillow and sheets.
The facility's policy regarding medication administration, dated November 21, 2024, indicated that gloves should be worn whenever dosage forms are handled.
Physician's orders for Resident 45, dated April 13, 2023, included an order for the resident to receive 81 milligrams (mg) of aspirin daily. Physician's orders for Resident 45, dated April 13, 2023, included an order for the resident to receive 50 micrograms (mcg) of cholecalciferol (vitamin D3) daily. Physician's orders for Resident 45, dated October 15, 2023, included an order for the resident to receive 8.6-50 mg of Senna-s (a laxative) twice daily.
Observations during medication administration on December 17, 2024, at 7:39 a.m. revealed that Licensed Practical Nurse 9 removed the medications listed above for Resident 45 from individual bottles into his bare hands. He then placed them into a medication cup with Resident 45's other medications and administered them to the resident.
Physician's orders for Resident 47, dated November 15, 2024, included an order for the resident to receive 1,000 mcg of vitamin B12 daily.
Observations during medication administration on December 17, 2024, at 7:39 a.m. revealed that Licensed Practical Nurse 9 poured a vitamin B12 tablet for Resident 47 from a bottle into his bare hands. He then placed the medication into a medication cup with Resident 47's other medication and administered it to the resident. He returned to the medication cart and proceeded to prepare medications for Resident 45 without performing hand hygiene.
Interview with Licensed Practical Nurse 9 on December 17, 2024, at 7:52 a.m. confirmed that he should have performed hand hygiene after administering medications to Resident 47 and before preparing medications for Resident 45 and confirmed that he should not have poured the medications for Residents 45 and 47 into his bare hands.
Interview with the Director of Nursing on December 17, 2024, at 11:58 a.m. confirmed that nurses should perform hand hygiene between residents when administering medications and should not place medications in ungloved, bare hands.
A quarterly MDS assessment for Resident 76, dated December 6, 2024, revealed that the resident was cognitively intact, received dialysis, and had diagnoses that included renal failure.
A nursing note for Resident 76, dated December 2, 2024, at 9:30 p.m. revealed that the resident was re-admitted from the hospital and had a dialysis port to her right side. A physician's order for the resident, dated December 2, 2024, included an order for staff to cover the resident's dialysis catheter with plastic wrap prior to showers. A physician's order, dated December 17, 2024, included an order for EBP.
Observations of Resident 76 on December 16, 2024, at 9:13 a.m. revealed that the resident had no signage at the entrance to her room or in her room to indicate infection control measures for EBP were in place related to her dialysis catheter.
Interview with the Assistant Director of Nursing/Infection Preventionist on December 19, 2024, at 10:27 a.m. confirmed that Resident 76 did not have EBP in place related to her dialysis catheter until December 17, 2024.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on review of planned, written menus, and recipes, as well as observations and staff interviews, it was determined that the facility failed to follow their pre-approved planned menu and recipes. ...
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Based on review of planned, written menus, and recipes, as well as observations and staff interviews, it was determined that the facility failed to follow their pre-approved planned menu and recipes.
Findings included:
Review of the posted menus for the lunch meal on Thursday, December 19, 2024, revealed that residents were to receive chicken vegetable stew, spaghetti noodles, dinner roll, pineapple tidbits with cream, two-percent milk, coffee/tea, and margarine.
A facility recipe card for chicken and vegetable stew, dated September 6, 2015, indicated that the chicken and vegetable stew contained the following 19 ingredients: fully cooked 1/2-inch diced chicken that was 80 percent dark and 20 percent white, chopped ham, chicken broth, baby lima beans, corn, crushed tomatoes, diced celery, chopped onions, minced garlic, ketchup, red wine vinegar, sugar, Worcestershire sauce, paprika; marjoram, pepper, salt, hot sauce, and margarine.
Observations on December 19, 2024, at 11:46 a.m. during the lunch tray delivery revealed that the residents received a bowl containing the spaghetti noodles and the chicken vegetable stew, and a small bowl containing the pineapple tidbits. However, there was no dinner roll or margarine placed on the residents' lunch tray.
Observations during a test tray on December 19, 2024, at 12:00 p.m. revealed that the Chicken Vegetable Stew did not contain any chopped ham, lima beans, crushed tomatoes, diced celery, and minced garlic, the Pineapple Tidbits did not contain a cream, and there was no dinner roll on the tray.
Interview with the Dietary Manager on December 19, 2024, at 12:04 p.m. confirmed that the dinner roll and margarine were not placed on the residents' trays, and that the pineapple tidbits did not contain the cream. He indicated that the cream was to be delivered today on the truck.
Interview with [NAME] 8 on December 19, 2024, at 12:25 p.m. revealed that the supply truck had not arrived yet and that he tried to make the Chicken Vegetable Stew as hardy as possible with what he had available.
There was no documented evidence that the change in the menu was discussed with the resident council president.
28 Pa. Code 211.6(a) Dietary Services.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident or the resident's representative was notifi...
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Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident or the resident's representative was notified about a transfer to the hospital and changes in medication orders for one of four residents reviewed (Resident 1).
Findings include:
The facility's policy regarding residents' rights, dated November 21, 2024, revealed that the facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is a need to alter treatment significantly or when there is a decision to transfer the resident from the facility.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated August 1, 2024, revealed that the resident had moderate cognitive impairment, required assistance from staff for daily care needs, and had diagnoses that included epilepsy (chronic brain disorder that causes seizures) and gastrointestinal stromal tumor (type of cancer that begins in the digestive system).
A nursing note for Resident 1, dated November 9, 2024, at 3:18 p.m., revealed that the resident was acting different and was not responding to staff. The resident was transported to the hospital for evaluation. A nurse's note, dated November 9, 2024, at 3:18 p.m., revealed that Resident 1 was admitted to the hospital with a diagnosis of status epilepticus (prolonged seizure). There was no documented evidence that a representative for the resident was notified of the resident's transfer to the hospital.
Physician's orders for Resident 1, dated November 24, 2024, included an order for the resident to receive 500 milligrams (mg) of Keppra (medication used to control seizures) two times a day. Physician's orders, dated November 26, 2024, included an order for the resident to receive 20 mg of Pantoprazole (medication used to treat heartburn and certain other conditions caused by too much acid in the stomach) at bedtime.
There was no documented evidence that Resident 1 or a representative of Resident 1 was notified about the above-mentioned medication changes.
Interview with the Director of Nursing on December 2, 2024, at 2:51 p.m. confirmed that neither Resident 1 nor a representative for Resident 1 was notified about the changes in the above-mentioned medications, and that a resident representative was not notified of the resident's transfer to the hospital on November 9, 2024.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
Jun 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure that a reasonable accommodation of a resident's preferences for toileting was ...
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Based on clinical record reviews, and resident and staff interviews, it was determined that the facility failed to ensure that a reasonable accommodation of a resident's preferences for toileting was provided for two of six residents reviewed (Residents 1, 2).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 7, 2024, revealed that the resident was understood and able to understand others, required assistance with care needs, was frequently incontinent of bowel and bladder, and had a diagnosis of Malignant Carcinoid Tumor of Stomach (stomach cancer). A care plan for Resident 1, revised on April 12, 2024, revealed that the resident had a potential for alteration in bowel elimination related to the need for assistance with toilet use, occasional incontinence, occasional diarrhea, bouts of constipation, and GI tumor.
An interview with Resident 1 on June 20, 2024, at 5:24 p.m. revealed that she does not get toileted during meals. She stated that the staff are not allowed to toilet residents until after meal trays are passed out and collected due to it being an infection control issue. She stated she has bowel issues with a recent cancer diagnosis and when she has to go, she has to go and cannot wait. She stated that she often incontinent and feels that is not right. The resident indicated that she often needs to go to the bathroom during mealtimes and is often incontinent because she has to wait.
A quarterly MDS assessment for Resident 2, dated May 9, 2024, revealed that the resident was cognitively intact, was understood and understands others, required assistance with care needs and was occasionally incontinent of urine.
An interview with Resident 2 on June 20, 2024, at 8:42 a.m. revealed that she frequently gets urinary tract infections (infection involving any part of the urinary system including the kidney, ureters, bladder and urethra) and has to go to the bathroom frequently. She stated that she is not allowed to go to the bathroom while meal trays are being passed and until the meal trays are collected, that it can be an hour until she gets to go to the bathroom, and that she uses the bedpan when she is in bed. If she is up in wheelchair, she uses the toilet and is able to stand with walker to toilet. Nursing notes for Resident 2, dated March 7, 2024; March 24, 2024; and May 27, 2024, revealed that the resident had received orders for antibiotics on these dates to treat urinary tract infections.
An interview with Nurse Aide 1 on June 20, 2024, at 6:10 p.m. revealed that he does not toilet residents during mealtimes because he was told he was not allowed. He would not explain further as to why he was not allowed.
An interview with Nurse Aide 2 on June 20, 2024, at 6:15 p.m. revealed that she was taught in class not to toilet residents during mealtimes for infection control reasons. When asked what she would do if a resident did ask to be toileted during mealtimes, she stated that most of the residents will not ask, because they know not to.
Interview with the Director of Nursing and the Nursing Home Administrator on June 20, 2024, at 6:35 p.m. revealed that they believed it was an infection control issue and also a dignity issue for other residents that may be in the room eating while other residents were being toileted. They did state that if the residents needed to toilet during meals, it would be addressed and situational depending on individual resident need.
28 Pa. Code 201.29(j) Resident Rights.
Jan 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to fol...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders for two of 29 residents reviewed (Residents 61, 66).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 61, dated August 10, 2023, revealed that the resident was alert and oriented and required extensive assistance with care.
Physician's orders for Resident 61, dated May 4, 2023, included an order for the resident to have a size 18F, 30 cc indwelling foley catheter (a thin, flexible catheter used to drain urine from the bladder).
Observations on January 10, 2024, at 10:08 a.m. revealed that Resident 61 had a size 18F, 10 cc indwelling foley catheter in place.
Interview with the Director of Nursing on January 11, 2024, at 11:29 a.m. confirmed that the foley catheter in place for Resident 61 was not what the physician ordered.
A significant change MDS assessment for Resident 66, dated December 23, 2023, revealed that the resident was cognitively intact, required extensive assistance for daily care needs, and had a diagnosis of Type 2 diabetes.
Physician's orders for Resident 66, dated September 7, 2023, indicated that the resident was to be given Humalog insulin (fast acting insulin) subcutaneously (under the skin) with meals, depending on the resident's blood sugar level. For a blood sugar greater than 500 milligrams per deciliter (mg/dL) the physician was to be notified.
The medication administration record (MAR) for Resident 66 for December 2023 indicated that her blood sugar level on December 8, 2023, at 12:30 p.m. was 530 mg/dL.
There was no documented evidence that the physician was notified of Resident 66's elevated blood sugar levels over 500 mg/dL as ordered.
Interview with the Assistant Director of Nursing on January 10, 2024, at 11:35 a.m. confirmed that there was no documented evidence that the physician was notified of the Resident 66's elevated blood sugar as ordered and there should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 29 residents reviewed (Resident 55).
Fi...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow recommendations from a wound consultation for one of 29 residents reviewed (Resident 55).
Findings include:
An admission Minimum Data Set (MDS) for Resident 55, dated October 7, 2023, revealed that the resident had diagnoses that included COPD (congestive obstructive pulmonary disease- a lung disease), was cognitively intact, required extensive assistance from staff for personal care needs, had a history of pressure ulcers on the sacrum and behind the ears, and a need for palliative care (focuses on providing relief from pain and other symptoms of a serious illness).
Review of wound consultation notes for Resident 55, dated November 21 and 28, 2023, and December 5, 2023, and January 11, 2024, revealed that pressure from the oxygen tubing was contributing to the resident having continued off and on skin breakdown behind the ears. Wound consultant recommendations included the continued use of foam protectors on the oxygen tubing behind the residents ears.
Physician's orders for Resident 55, dated December 27, 2023, included an order for the resident to receive oxygen from 4 to 8 liters per minute via nasal canula. The resident's pressure ulcer care plan, dated November 30, 2023, included a goal that the skin will remain free of breakdown within the limits of the disease.
Observations of Resident 55 on January 8 and 9, 2024, revealed no foam ear protectors behind his ears. An interview with the resident on January 11, 2024, indicated that he did not mind wearing ear protectors.
Interview with the Director of Nursing on January 11, 2024, at 1:29 p.m. confirmed that staff did not follow through as recommended by the wound consultant and they should have.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to conduct an air mattress safety assessment for one of 29 re...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to conduct an air mattress safety assessment for one of 29 residents reviewed (Resident 33) and failed to ensure that the residents' environment remained as free of accident hazards as possible by transporting a resident without leg rests for one of 29 residents reviewed (Resident 139).
Findings include:
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 33, dated May 8, 2023, revealed that he was cognitively impaired, required extensive assistance from staff for care, and had an indwelling urinary catheter. A care plan for the resident, dated June 2, 2023, revealed that he was at risk for falls due to balance, and interventions, dated July 13, 2023, included an alternating air mattress.
A nursing note for Resident 33, dated July 10, 2023, at 9:30 p.m., indicated that the nurse was called to resident's room by a nurse aide. The resident was lying on his right side on the floor beside his bed, his pillow was under his head, and his blankets were covering him. He had his soft boots on his feet. The bed was in low position. The resident was unable to say how he got on the floor. He was on a FLOWT mattress and was dependent on staff for repositioning. The call bell was not ringing. The resident had no shortening or rotation of the extremities. The resident had a 3.0 centimeter (cm) by 3.0 cm bruise on forehead and another 3.0 cm x 3.0 cm bruise on top of his head. Neurological check was within normal limits. The doctor was notified.
A nursing note for Resident 33, dated November 3, 2023, at 10:33 a.m., revealed that the registered nurse was notified by nurse aide that the resident was on the floor. Upon entering the room the resident was lying on the right side of the bed on his right side with head towards the dresser. No injuries were noted. The resident was contracted per normal. Nurse aides were last in the room at approximately 7:50 a.m. and sat the resident midline in bed to eat breakfast. The resident stated oh my when asked what he was trying to do. The resident denied any pain or discomfort. The resident returned to bed via a mechanical lift. The Certified Registered Nurse Practitioner (CNRP-advanced practice nurse) was notified and an order was received for bilateral fall mats.
A nurse's note for Resident 33, dated November 3, 2023, at 11:03 a.m., revealed that the resident was noted to have a red hematoma to the right side of his head. Neurological checks were within normal limits, and pupils were equal and reactive to light. The physician was updated.
A nursing note for Resident 33, dated November 12, 2023, at 9:45 p.m., revealed that the registered nurse was called to the resident's room by the licensed practical nurse. The resident was lying on his left side between the bed and wall on the floor mat, and his head was slightly off the mat. The bed was in the low position, he had nonskid socks on his feet, and the call bell was in reach but was not ringing. No injuries were noted. The resident did not know how it happened. Neurological checks within normal limits, no complaints of pain with movement of extremities, and no shortening or rotation of extremities were noted. The doctor was notified, and new order for alarms was received.
There was no documented evidence in Resident 33's clinical record to indicate that an air mattress assessment was completed to determine if the resident would be safe while on the mattress.
An interview with the Director of Nursing and Assistant Director of Nursing on January 11, 2024, at 2:47 p.m. confirmed that the facility did not do a bed safety assessment on the resident after he was placed on the air mattress.
The facility's policy for assistive devices and equipment, dated September 21, 2023, indicated that residents being transported by staff will utilize wheelchair leg rests.
Diagnoses for Resident 139 on admission January 10, 2024, included a history of falls at home and degeneration of the nervous system (damage to the nervous system which can result in physical disabilities).
Observations of Resident 139 on January 10, 2024, at 11:40 a.m. revealed that the resident was sitting in a wheelchair in his room when Nurse Aide 1 placed her hands on the wheelchair's handle bars and transported the resident down the hallway to obtain an admission weight. The resident was wearing non-skid socks and he was holding his feet up away from the floor. It was noted that there were no leg rests on the wheelchair.
Interview with Nurse Aide 1 on January 10, 2024, at 11:54 a.m. revealed that she transported Resident 139 down the hall to obtain an admission weight without leg rests on the wheelchair and she should not have.
Interview with Director of Nursing on January 10, 2024, at 12:28 p.m. confirmed that Resident 139 should have had leg rests on his wheelchair while being transported.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on review of policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that physician's orders for enteral feedings (feeding through a tube inserted ...
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Based on review of policies, clinical records, and staff interviews, it was determined that the facility failed to ensure that physician's orders for enteral feedings (feeding through a tube inserted directly into the stomach) were followed for one of 29 residents reviewed (Resident 79).
Findings include:
The facility's policy regarding enteral feeding, dated September 21, 2023, indicated that the enteral nutrition is based on a dietician's nutritional assessment. Physician's orders for enteral nutrition are based off the recommendations from the dietician.
A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 79, dated November 7, 2023, indicated that the resident was cognitively intact and required assistance from staff for care.
Physician's orders for Resident 79, dated November 16, 2023, included an order for the resident to receive a bolus (one meal of formula) of Osmolite (a type of formula) four times a day (9:00 a.m., 1:00 p.m., 6:00 p.m., and 8:00 p.m.) for meal intakes that were less than 50 percent.
Review of Resident 79's meal intake records for November 2023 revealed that the resident ate more than 50 percent of meals on November 23, 28, and 29, 2023; however, the resident's Medication Administration Record (MAR) for November 2023 revealed that staff administered a bolus of Osmolite following meals on those dates.
Interview with the Registered Dietician on November 11, 2023, at 8:27 a.m. confirmed that staff did not follow physician's orders for Resident 79 regarding her tube feeding on the above days.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on review of clinical records and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for o...
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Based on review of clinical records and staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in significant medication errors for one of 29 residents reviewed (Resident 1).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 28, 2023, revealed that the resident was cognitively intact, received an anticoagulant (blood thinner to prevent blood clots) medication, and had diagnoses that included end-stage renal disease (kidney failure).
Physician's orders for Resident 1, dated April 30, 2023, included an order for the resident to receive 2.5 milligrams (mg) of Eliquis (an anticoagulant) two times a day.
A nursing note for Resident 1, dated December 27, 2023, revealed that the resident's Eliquis orders were put on hold due to surgery on December 29, 2023. Nursing staff were to check when the Eliquis was to be resumed after surgery was completed.
A nursing note for Resident 1, dated December 29, 2023, at 7:30 p.m. revealed that Resident 1 was to resume taking Eliquis on December 30, 2023.
Review of the Medication Administration Record (MAR) for Resident 1 for December 2023 and January 2024 revealed that the resident was not administered Eliquis as ordered between December 30, 2023, and January 8, 2024.
Interview with the Director of Nursing and the Assistant Director of Nursing on January 10, 2024, at 12:27 p.m. confirmed that Eliquis should have been resumed for Resident 1 on December 30, 2023, but as of January 8, 2024, it was not.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews, it was determined that the facility failed to ensure that medications were appropriately secured within the medication carts for one of four medication cart...
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Based on observations and staff interviews, it was determined that the facility failed to ensure that medications were appropriately secured within the medication carts for one of four medication carts reviewed (Hall B) and failed to ensure that labeling of medication matched physician's orders for one of 29 residents reviewed (Resident 59).
Findings include:
Observations of a medication cart on Hall B on January 10, 2024, at 11:58 a.m. revealed that the first of four large drawers in the medication cart contained four unidentified, loose pills; the second large drawer contained three unidentified, loose pills; and the fourth large drawer contained two unidentified, loose pills that were unsecured and not in the pharmacy's packaging. Interview with Licensed Practical Nurse 2 at that time confirmed that the pills were loose in the bottom of the cart drawers and should not have been.
Interview with the Director of Nursing on January 10, 2024, at 12:28 p.m. confirmed that there were unidentified loose medications in the drawers of the Hall B medication cart.
Physician's orders for Resident 59, dated November 3, 2023, included an order for the resident to receive 5 milligrams (mg) of Reglan (a medicine related to gastroesophageal reflux - a stomach disorder) every six hours (midnight, 6:00 a.m., 12:00 p.m., and 6:00 p.m.). A review of the pill card (a way of packaging medications that are grouped by the time and day of taking them) for Resident 59's Reglan revealed that the pharmacy had placed several additional labels (stickers) on the pill card related to the medication. One label advised that the resident was to receive Reglan 30 minutes prior to meals.
Observations during B hall medication pass on January 9, 2024, revealed that Licensed Practical Nurse 3 administered Resident 59's 12:00 p.m. medications at 1:28 p.m. (which included Reglan). It was observed at this time that Resident 59's lunch meal tray had been picked up by staff. Interview with Licensed Practical Nurse 3 at that time revealed that she was helping in the dining room with lunch and now her noon medication pass was late. In addition, she indicated that she did not notice the pharmacy label (sticker) on the pill card that advised Reglan was to be given 30 minutes prior to meals. She further revealed that the electronic medication administration record did not indicate that Reglan was to be given 30 minutes prior to meals.
A review of facility mealtimes indicated that Resident 59's lunch had been served at approximately 11:40 a.m.
Interview with the Nursing Home Administrator and Assistant Director of Nursing on January 10, 2024, at 10:54 a.m. confirmed that the facility failed to ensure that physicians orders, pharmacy recommendations, and the electronic medication administration record all matched for Resident 59's Reglan order.
28 Pa. Code 211.9(h) Pharmacy services.
28 Pa. Code 211.9(a)(1) Pharmacy services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service ...
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Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to serve food in accordance with professional standards for food service safety by failing to ensure that dietary staff wore beard coverings that completely covered their beard during food handling.
Findings include:
The facility's dietary policy regarding personal hygiene, dated September 21, 2023, revealed that staff were to cover all hair and facial hair with restraint, either with a hairnet, cap, or hat.
Observations in the kitchen on January 10, 2024, at 11:10 a.m. revealed dietary staff at the stove preparing chicken pot pie for the resident's lunch. Dietary Aide 4 was observed with approximately four to five inches of his beard not contained within the beard net.
Interview with the Dietary Director on January 10, 2024, at 11:15 a.m. confirmed that Dietary Aide 4 did not have all of his beard covered with a restraint as he should have.
Interview with Nursing Home Administrator on January 10, 2024, at 3:46 p.m. confirmed that Dietary Aide 4 should have had all of his beard covered.
28 Pa. Code 211.6(f) Dietary services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending February 8, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 11, 2024, identified repeated deficiencies related to a failure to ensure quality of care and a failure to ensure labeling and storage of medications.
The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending February 8, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to maintain ongoing compliance with the regulations regarding quality of care services.
The facility's plan of correction for a deficiency regarding labeling and storage of medications, cited during the survey ending February 8, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the QAPI committee failed to maintain ongoing compliance with the regulations regarding labeling and storage of medications.
Refer to F684, F761.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing techniques were used during medication administ...
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Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper hand washing techniques were used during medication administration for three of five residents observed (Residents 17, 59, 83).
Findings include:
The facility's policy regarding hand hygiene, dated September 21, 2023, indicated that all employees were to follow the hand washing procedure, which included hand sanitizing, before preparing or handling medications.
Observations during the medication pass in B hall on January 9, 2024, at 1:20 p.m. revealed that Licensed Practical Nurse 3 prepared Resident 83's medications and administered them. Without sanitizing her hands she prepared and administered Resident 59's medications. She then went to Resident 17's room and without sanitizing her hands she prepared and administered her medications. Licensed Practical Nurse 3 then washed her hands in the sink and exited the resident's room.
Interview with Licensed Practical Nurse 3 on January 9, 2024, at 1:20 p.m. confirmed that she should have sanitized her hands between residents while doing the medication pass.
Interview with the Assistant Director of Nursing on January 9, 2024, at 2:10 a.m. confirmed that Licensed Practical Nurse 3 did not properly sanitize her hands during medication administration and she should have.
28 Pa. Code 211.12(d)(5) Nursing services.
Mar 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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during inc...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during incontinent care for one of 15 residents reviewed (Resident 6).
Findings include:
The facility's policy for personal protective equipment - using gloves, dated September 30, 2022, indicated that staff are to use non-sterile gloves to prevent contamination of the employees hands when providing treatment or services to the resident. Staff are to wash hands after glove removal.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 8, 2022, revealed that she had long and short-term memory problems, required extensive assistance for her care, and was always incontinent of urine and bowel.
Observations of Resident 6 on March 7, 2023, at 8:53 a.m. revealed that she was provided a bath and incontinent care. During care Nurse Aide 1 cleansed the resident's upper body then applied gloves and provided incontinent care of bowel movement, then removed her gloves. Without any hand hygiene Nurse Aide 1 proceeded to dress the resident, move a TV control and box of tissues onto her roommate's over-bed table, and then obtained a mechanical lift to transfer Resident 6.
Interview with Nurse Aide 1 on March 7, 2023, at 8:53 a.m. indicated that she should have had gloves on for all of Resident 6's morning care and should have washed her hands after the glove removal.
Interview with the Director of Nursing on March 7, 2023, at 10:49 a.m. confirmed that staff are to don gloves for bathing residents and the gloves should be removed and hand hygiene performed after incontinent care and prior to doing further care.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Feb 2023
16 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of t...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative following the end of their Medicare coverage or a 48-hour advanced notice for one of three residents reviewed (Resident 90). This deficiency was cited as past non-compliance.
Findings include:
A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form, completed by the facility and dated November 5, 2022, revealed that Medicare coverage for Resident 90 started on October 9, 2022, and that her last covered day was November 5, 2022. The form indicated that the facility initiated discontinuation from Medicare Part A coverage and that the resident's benefit days were not exhausted. The form was signed by the resident's representative on November 3, 2022. The facility had no documented evidence that the resident was issued a SNF Beneficiary Protection Notification form or an Advanced Beneficiary Notice (ABN) notice as required.
Interview with Business Office Manager on February 7, 2023, at 2:19 p.m. confirmed Resident 90 did not have an ABN completed timely.
Interview with Nursing Home Administrator on February 7, 2023, at 2:19 p.m. also confirmed the ABN was not completed and that it should have been.
The facility identified the missing SNF ABN form on January 31, 2023. The facility refunded the resident's private pay days. A Medicare beneficiary audit for the past three months was completed and showed no additional findings. The facility's Quality Assurance Performance Improvement (QAPI) plan was to review issuing Advanced Beneficiary Notices on appropriate residents during the daily skilled review meeting, as well as during the triple check meeting at the beginning of each month. Education was provided to the Registered Nurse Assessment Coordinator, licensed practical nurse, and Business Office Manager. Results of the audits were reviewed during Quality Assurance Performance Improvement meetings. The date of compliance was completed on January 31, 2023.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews, it was determined that the facility failed to ensure that residents had a clean and homelike environment, by failing to ensure that residents' wheelchairs w...
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Based on observations and staff interviews, it was determined that the facility failed to ensure that residents had a clean and homelike environment, by failing to ensure that residents' wheelchairs were in good repair for two of 33 residents reviewed (Residents 6, 47).
Findings include:
A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated December 7, 2022, indicated that the resident was cognitively impaired, required extensive assistance from staff for daily care tasks, used a wheelchair, and had diagnoses that included Parkinson's (a disease that causes tremors, stiffness or slowing of movement) and dementia.
Observations of Resident's 6 wheelchair on February 8, 2023, at 8:30 a.m. and 3:06 p.m. revealed that the leather on the arm rests on both sides of the wheelchair was worn away, cracked, and had edges that were peeling off.
A Quarterly MDS for Resident 47, dated January 8, 2023, indicated that the resident was cognitively impaired, required extensive assistance from staff for daily care tasks, used a wheelchair, and had diagnoses that included quadriplegia (a condition that causes both arms and legs to have no motor function) and dementia.
Observations of Resident 47's wheelchair on February 6, 2023, at 11:30 a.m. and February 8, 2023, at 3:06 p.m. revealed that the leather of the arm rests on both sides of the wheelchair was worn away, cracked, and had edges that were peeling off.
Interview with the Maintenance Director on February 8, 2023, at 3:06 p.m. confirmed that Resident 6's and Resident 47's wheelchairs were worn and that the leather armrests should have been repaired or replaced.
28 Pa. Code 201.29(j) Resident rights.
28 Pa. Code 207.2(a) Administrator's responsibility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on review of the Resident Assessment Instrument (RAI) User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Dat...
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Based on review of the Resident Assessment Instrument (RAI) User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for two of 34 residents reviewed (Residents 51, 58).
Findings include:
The RAI User's Manual, dated October 2019, revealed that if a chair alarm was used, then Section P0200B was to be coded as (0) not used, (1) used less than daily, or (2) used daily.
Physician's orders for Resident 51, dated August 31, 2022, included orders for the resident to use a chair alarm (device that alarms when standing up from chair). A care plan, dated March 10, 2022, indicated that the resident was to use a chair alarm on her wheelchair. The resident's Activities of Daily Living report for November 2022 revealed that the resident used a chair alarm from November 1-30, 2022.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated November 22, 2022, revealed that Section P0200B was coded with a (0), indicating that the resident did not use a chair alarm.
The RAI User's Manual, dated October 2019, revealed that Section N was to record the number of days during the last seven days (or since admission/entry or reentry if less than seven days) that specific types of medications were received by the resident. Section N0410B was to indicate how many days the resident received an antianxiety during the seven-day review period.
Current physician's orders for Resident 58, included orders for the resident to receive 20 milligrams (mg) of Paroxetine (an antianxiety/antidepressant) daily for major depressive disorder and 3.75 mg of Tranxene (an antianxiety) at bedtime for insomnia. The resident's Medication Administration Record (MAR) for November 2022 revealed that she received Paroxetine HCL daily and Tranxene at bedtime from November 2 to 8, 2022.
A quarterly MDS assessment, dated November 8, 2022, revealed that Section N0410B was coded with a zero (0), indicating that the resident did not receive an antianxiety during the seven-day review period.
Interview with the Registered Nurse Assessment Coordinator on February 8, 2023, at 1:58 p.m. confirmed that the November 22, 2022, MDS for Resident 51 and the November 8, 2022, MDS for Resident 58 were coded incorrectly.
28 Pa. Code 211.5(f) Clinical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on Review of Pennsylvania's Nursing Practice Act and information submitted from the facility, it was determined that the facility failed to ensure that a registered nurse's license remained curr...
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Based on Review of Pennsylvania's Nursing Practice Act and information submitted from the facility, it was determined that the facility failed to ensure that a registered nurse's license remained current for one of one registered nurse reviewed (Registered Nurse 1).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, for the expiration and renewal of licensure revealed that notice of the renewal period of a license will be sent to each active licensee prior to the expiration date of the licensee's license. The applicant for license renewal may complete and submit an application online or may mail a completed application form to the Board's administrative office. When applying for licensure renewal, a registered nurse shall complete and submit the renewal application, including disclosing any license to practice nursing or any allied health profession in any other state, territory, possession or country, pay the biennial renewal fee, verify the completion of mandatory continuing education and child abuse recognition and reporting requirements, disclose any discipline imposed by a state licensing board on any nursing or allied health profession license or certificate in the previous biennial period, and any criminal charges pending or criminal conviction, plea of guilty or nolo contendere, admission into a probation without verdict, or accelerated rehabilitation during the previous biennial period.
Information submitted by the Nursing Home Administrator on February 8, 2023, revealed that Registered Nurse 1's license was suspended on September 8, 2022, and that she continued to work from September 8, 2022, until November 18, 2022. No care concerns were identified during this time.
Registered Nurse 1 was terminated on November 18, 2022, after it was discovered that her license was suspended and that she was uncooperative with the licensing agency.
An interview with the Nursing Home Administrator on February 8, 2023, at 2:38 p.m. revealed that the facility suspended Registered Nurse 1 when they learned that her license had been suspended and that Registered Nurse 1 did not tell the facility that her license was suspended at the time that it occurred.
28 Pa. Code 201.14(a) Responsibility of license.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of 34 residents rev...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of 34 residents reviewed (Residents 41, 48).
Findings include:
An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated November 16, 2022, revealed that the resident was cognitively intact, required extensive assist with daily care needs, had diagnoses that included diabetes (a disease that interferes with blood sugar control), and received insulin.
Physician's orders for Resident 41, dated December 7, 2022, included an order for the resident to receive 10 units of Novolog insulin subcutaneously (injected just under the skin) four times a day, to check the resident's blood sugar before administering, and to call the physician if the blood sugar is less than 70 milligrams per deciliter (mg/dl) or greater than 400 mg/dl. A physician's order, dated January 23, 2023, included for the resident to receive 12 units of Novolog insulin subcutaneously four times a day, to check the resident's blood sugar before administering, and to call the physician if the blood sugar is less than 70 mg/dl or greater than 400 mg/dl.
A review of the Medication Administration Records (MAR's) for Resident 41, dated December 2022 and January 2023, revealed that on December 10, 2022, at 5:15 p.m. the resident's blood sugar was 408 mg/dl; on December 25, 2022, at 5:15 p.m. the resident's blood sugar was 405 mg/dl; on January 16, 2023, at 8:00 p.m. the resident's blood sugar was 412 mg/dl; and on January 27, 2023, at 5:15 p.m. the resident's blood sugar was 404 mg/dl. There was no documented evidence that the physician was notified of these elevated blood sugars as ordered.
A significant change MDS for Resident 48, dated January 12, 2023, revealed that the resident was understood and understands, required extensive assist with daily care needs, had diagnoses that included diabetes (a disease that interferes with blood sugar control), and received insulin.
Physician's orders for Resident 48, dated December 30, 2022, included orders for the resident to receive 7 units of Novolog insulin subcutaneously three times a day, and to call the physician if the blood sugar was less than 70 mg/dl or greater than 400 mg/dl. Physician's orders, dated January 12, 2023, included orders for the resident to receive 9 units of Novolog insulin subcutaneously two times a day, and to call the physician if the blood sugar was less than 70 mg/dl or greater than 400 mg/dl.
A review of the MAR for Resident 48, dated January, 2023, revealed that on January 21, 2023, at 5:00 p.m. the resident's blood sugar was 453 mg/dl; on January 19, 2023, at 5:00 p.m. the resident's blood sugar was 462; and on January 16, 2023, at 5:00 p.m. the resident's blood sugar was 581 mg/dl. There was no documented evidence that the physician was notified of these elevated blood sugars as ordered.
Interview with the Director of Nursing on February 8, 2023, at 9:33 a.m. confirmed that the physician was not notified of Residents 41 and 48's elevated blood sugars mentioned above, and he should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one o...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that each resident received assistance devices to prevent accidents for one of 34 residents reviewed (Resident 24).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated January 31, 2023, revealed that the resident was cognitively intact, required extensive assistance for daily care needs including transfers and locomotion, and had diagnoses that included the presence of an artificial knee joint and a history of falls.
Observation of Resident 24 on February 6, 2023, at 12:11 p.m. revealed that the resident was sitting in a wheelchair while being transported to her room by Activity Aide 2. There were no footrests on her wheelchair to prevent her feet from dragging during the transport. An interview with Activity Aide 2 at that time confirmed that the resident should have had leg rests on her wheelchair to prevent injury during the transport.
An interview with the Director of Nursing on February 7, 2023, at 12:00 p.m. confirmed that footrests should have been used when transporting Resident 24 in her wheelchair.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infectio...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide appropriate care to prevent urinary tract infections for one of 34 residents reviewed (Resident 51) who had an indwelling urinary catheter.
Findings include:
The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine), dated September 30, 2022, revealed that catheter drainage bags and tubing were to be kept off the floor.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 51, dated November 22, 2022, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care activities, used a wheelchair, was frequently incontinent of urine, and had diagnoses that included dementia.
Physician's orders, dated February 1, 2023, included an order for the resident to have a urinary catheter, 18 French (size) with a 10 cubic centimeters (cc) balloon (located on the bladder end of the catheter and filled with sterile water to hold the tube in place).
Observations of Resident 51 on February 7, 2023, at 7:46 a.m. and 8:22 a.m. revealed that the resident was in a Broda chair (specialized chair) in the hallway and her catheter tubing was in contact with the floor.
Interview with Licensed Practical Nurse 3 on February 7, 2023, at 12:32 p.m. confirmed that Resident 51's catheter tubing was on the floor and should not have been.
Interview with the Director of Nursing on February 7, 2023, at 11:39 a.m. confirmed that Resident 51's catheter tubing should not have been in contact with the floor.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0729
(Tag F0729)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility job descriptions and personnel files, as well as staff interviews, it was determined that the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility job descriptions and personnel files, as well as staff interviews, it was determined that the facility failed to ensure that staff renewed their nurse aide registry to allow individuals to work as a nurse aide for one of three nurse aides reviewed (Nurse Aide 4).
Findings include:
The facility's job description, undated, revealed that a nurse aide certification was necessary to perform functions of the position.
The personnel file for agency Nurse Aide 4 revealed that her certification on the nurse aide registry expired on [DATE]. The facility was unaware that Nurse Aide 4's certification on the nurse aide registry had expired until they were contacted on [DATE], by the agency that Nurse Aide 4 was employed with. Nurse Aide 4 worked in the facility on [DATE], 23, and 25, 2022.
Interview with the Nursing Home Administrator on February 8, 2023, at 2:38 p.m. confirmed that Nurse Aide 4's certification on the nurse aide registry expired on [DATE], and should have been renewed prior to expiring and working in the facility.
28 Pa. Code 201.29 Personnel policies and procedures.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on review of policies, clinical records, and pharmacy packing slips, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medication...
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Based on review of policies, clinical records, and pharmacy packing slips, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications for two of 34 residents reviewed (Residents 3, 47).
Findings include:
The facility's policy regarding documentation of medication management, dated September 30, 2022, indicated that the facility shall maintain a medication administration record to document all medications administered. A nurse should document all medications administered to each resident on the resident's medication administration record.
Physician's orders for Resident 3, dated December 23, 2022, included an order for the resident to receive one 5-325 milligram (mg) tablet of Hydrocodone-Acetaminophen (a combination controlled narcotic) every six hours as needed for moderate/severe pain.
Review of Resident 3's controlled drug record for December 2022 revealed that staff signed out a dose of Hydrocodone-Acetaminophen for administration to the resident on December 23, 2023, at 4:00 p.m. However, there was no documented evidence in the resident's clinical record, including on the MAR and nursing notes, that the signed out dose of Hydrocodone-Acetaminophen was actually administered to the resident.
Physician's orders for Resident 47, dated January 4, 2023, included an order for the resident to receive one 50 milligram (mg) tablet of Tramadol (a controlled narcotic) every eight hours as needed for pain.
Review of Resident 47's controlled drug record, dated January 2023, revealed that staff signed out a dose of Tramadol for administration to the resident on January 21, 2023, at 8:00 p.m. However, there was no documented evidence in the resident's clinical record, including on the MAR and nursing notes, that the signed out dose of Tramadol was actually administered to the resident.
Interview with Director of Nursing on February 7, 2023, at 3:37 p.m. confirmed that controlled drugs were to be signed out on the controlled drug log, administered to the resident, and then signed as administered on the MAR. The Director of Nursing also confirmed that there was no documented evidence in Resident 3's and Resident 47's clinical records to indicate that the signed-out doses of controlled medications were actually administered to the residents.
28 Pa. Code 211.9(h) Pharmacy services.
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for ...
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Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 34 residents reviewed (Residents 20).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated November 11, 2022, revealed that the resident was cognitively impaired, required extensive assist of staff for daily care needs, and had diagnoses that included chronic kidney disease.
Physician's orders for Resident 20, dated February 21, 2022, included an order for the resident to be restricted to 1500 cubic centimeters (cc) of fluids in every 24-hour period.
A review of fluid intake records for Resident 20 for January 2023 and February 2023 revealed fluid intakes on January 2, 2023, of 1610 cc; January 4, 2023, of 4440 cc; January 11, 2023, of 1960 cc; January 13, 2023, of 1780 cc; January 26, 2023, of 1570 cc's; and on February 6, 2023, of 1880 cc. On these dates and times, the fluid intake for the resident exceeded the 1500 cc fluid intake ordered by the physician.
An interview with the Director of Nursing on February 7, 2023, at 1:35 p.m. revealed that the fluid restriction totals for Resident 20 on the above dates and times were wrong because a nurse aide improperly documented the fluid intake for her shift.
28 Pa Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending March 10, 2022, and July 28, 2022, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 8, 2023, identified repeated deficiencies related to implementing abuse policies, accurate minimum data sets (MDS), safety, temperature and palatable food, and food storage and sanitary conditions.
The facility's plan of correction for a deficiency regarding implementing abuse policies, cited during the survey ending March 10, 2022, revealed that the implementation of abuse policies would be monitored by QAPI. The results of the current survey, cited under F607, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding resident dignity.
The facility's plan of correction for a deficiency regarding accurate MDS, cited during the survey ending March 10, 2022, revealed that MDS would be submitted accurately and that they would be monitored by QAPI. The results of the current survey, cited under F641, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding professional nursing services.
The facility's plan of correction for a deficiency regarding accident hazards, cited during the survey ending March 10, 2022, revealed that audits would be completed and the results would be presented at the quarterly QAPI meeting. The results of the current survey, cited under F689, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the residents' environment was free from accident hazards.
The facility's plans of correction for deficiencies regarding food temperatures and palatability of food, cited during the surveys ending March 10, 2022 and July 28, 2022, revealed that audits would be completed and the results would be presented at the quarterly QAPI meeting. The results of the current survey, cited under F804, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding food temperatures and palatability.
The facility's plan of correction for a deficiency food storage and sanitation, cited during the survey ending March 10, 2022, revealed that audits would be completed, and the results of the audits would be presented at the quarterly QAPI meeting. The results of the current survey, cited under F812, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding food storage and sanitary conditions.
Refer to F607, F641, F689, F804, F812.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on clinical record reviews, observations, and interviews with residents and staff, it was determined that the facility failed to ensure that a resident's care plan was updated for four of 33 res...
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Based on clinical record reviews, observations, and interviews with residents and staff, it was determined that the facility failed to ensure that a resident's care plan was updated for four of 33 residents reviewed (Residents 20, 45, 51, 63).
Findings include:
An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 20, dated November 11, 2022, revealed that the resident was cognitively impaired, required extensive assist of staff for daily care needs, and had diagnosis that included chronic kidney disease.
A review of the care plan for Resident 20, dated April 20, 2022, included the use of a right nephrostomy tube (thin plastic tube that is inserted through the skin and into the kidney).
A nurse's note for Resident 20, dated December 29, 2022, at 7:34 p.m. revealed that the resident had a right nephrostomy that was discontinued on July 6, 2022.
An interview with Director of Nursing on February 7, 2023, at 1:35 p.m. confirmed that Resident 20's care plan was not updated when the nephrostomy tube was discontinued, and it should have been.
A quarterly MDS for Resident 45, dated December 7, 2022, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. Resident 45's care plan, dated October 5, 2022, indicated that the resident was at risk for falls and had a bed and chair alarm.
Observations of Resident 45 on February 6, 2023, at 11:48 a.m. revealed that the resident did not have a bed or chair alarm.
Interview with the Registered Nurse Assessment Coordinator on February 8, 2023, at 4:12 p.m. revealed that Resident 45 did not have a bed or chair alarm and that they had been discontinued. She indicated that the resident's care plan was not updated to reflect the discontinuation of alarms and it should have been.
A quarterly MDS assessment for Resident 51, dated November 22, 2022, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care activities, was frequently incontinent of urine, and had diagnoses that included dementia.
Resident 51's care plan, dated February 2, 2023, indicated that the resident had a urinary tract infection with ESBL (enzymes produced by some bacteria that may make them resistant to some antibiotics.) and was to be on contact precautions.
Interview with the Assistant Director of Nursing on February 8, 2023, at 9:37 a.m. revealed that Resident 51 was not to be on contact isolation and had been treated with antibiotics while in the hospital.
An admission MDS assessment for Resident 63, dated January 20, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff for daily care activities, was frequently incontinent of urine, and had diagnoses that included dementia.
Physician's orders, dated January 17, 2023, included orders for the resident to be on contact and airborne precautions for COVID-19 and C-diff (Clostridium Difficile- bacteria that causes diarrhea), which were discontinued on January 23, 2023. Physician's orders, dated January 23, 2023, included orders for contact precautions for C-diff, which were discontinued on January 31, 2023.
Resident 63's current care plan, indicated that the resident had an infection of the colon with C-diff and was to maintain isolation precautions as indicated.
Interview with the Director of Nursing and Assistant Director of Nursing on February 8, 2023, at 11:10 a.m. confirmed that Resident 63's care plan should have been updated to reflect that the resident was no longer on isolation precautions.
28 Pa. Code 211.11(d) Resident care plans.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for two of 34 residents revie...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for two of 34 residents reviewed (Residents 41,48).
Findings include:
An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 41, dated November 16, 2022, revealed that the resident was cognitively intact, required extensive assist with daily care needs, had diagnoses that included diabetes (a disease that interferes with blood sugar control), and received insulin.
Physician's orders for Resident 41, dated December 7, 2022, included an order for the resident to receive 10 units of Novolog insulin subcutaneously (injected just under the skin) four times a day, to check the resident's blood sugar before administering, and hold the insulin if the resident's blood sugar was less than 150 milligrams per deciliter (mg/dL). Physician's orders, dated January 23, 2023, included orders for the resident to receive 12 units of Novolog insulin subcutaneously four times a day, to check the resident's blood sugar before administering, and to hold the insulin if the resident's blood sugar was less than 150 mg/dL.
A review of the Medication Administration Records (MAR's) for Resident 41, dated January 2023, revealed that the resident's blood sugar on January 9, 2023, at 8:00 a.m. was 132 mg/dl; on January 9, 2023, at 12:00 p.m. was 130 mg/dl; on January 9, 2023, at 5:15 p.m. was 141 mg/dl; and on January 6, 2023, at 8:00 a.m. was 141 mg/dl; on January 24, 2023, at 8:00 a.m. was 143 mg/dl; and on January 28, 2023, at 8:00 a.m. was 142 mg/dl. There was no documented evidence that the insulin was held for a blood sugar less than 150mg/dl on the mentioned dates and times as ordered by the physician.
A significant change MDS for Resident 48, dated January 12, 2023, revealed that the resident was understood and could understand, required extensive assist with daily care needs, had diagnoses that included diabetes, and received insulin.
Physician's orders for Resident 48, dated December 30, 2022, included orders for the resident to receive 7 units of Novolog insulin subcutaneously, three times a day, and hold the insulin if the resident's blood sugar was less than 150 mg/dL. Physician's orders, dated January 12, 2023, included orders for the resident to receive 9 units of Novolog insulin subcutaneously two times a day and hold the insulin if the resident's blood sugar was less than 150 mg/dL.
A review of the MAR for Resident 48, dated January 2023, revealed that the resident's blood sugar on January 4, 2023, at 8:00 a.m. was 104 mg/dl; on January 5, 2023, at 8:00 a.m. was 103; on January 6, 2023, at 8:00 a.m. was 130 mg/dl; on January 9, 2023, at 8:00 a.m. was 115 mg/dl; on January 14, 2023, at 8:00 a.m. was 111 mg/dl; on January 15, 2023, at 8:00 a.m. was 108 mg/dl; and on January 16, 2023, at 8:00 a.m. was 117 mg/dl. There was no documented evidence that the insulin was held as ordered for a blood sugar less than 150mg/dl on the mentioned dates and times.
Interview with the Director of Nursing on February 8, 2023, at 9:33 a.m. confirmed that Resident 41's and Resident 48's insulin was not held when their blood sugar was less than 150 mg/dL on the dates mentioned and should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on review of policies, clinical records, and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to properly secure and store me...
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Based on review of policies, clinical records, and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to properly secure and store medications, and failed to label a multi-dose vial of Tubersol (used for Tuberculin testing) and a bottle of eye drops for one resident (Resident 7) with the date they were opened, located in the medication room, and multi-dose insulin pens and vials with the date they were opened, located in two of four medication carts for (Residents 20, 41, 48, 87).
Findings include:
The facility's policy regarding medication storage, dated September 30, 2022, revealed that medications were to be stored in medication carts that were to be locked at all times and were not to be stored on top of the carts, insulin pens would be dated when opened, and that drugs and biologicals used in the facility were to be stored in locked compartments under proper temperature, light, and humidity controls.
Observations on February 8, 2023, at 7:59 a.m. revealed that there were two 10 milliliter (ml) normal saline (sterile salt water solution) flushes and two 50 units/5 ml of Heparin (blood thinner) flushes lying on the counter of the nurse's station unsecured and unattended.
Interview with the Assistant Director of Nursing on February 8, 2022, at 8:19 a.m. confirmed that the normal saline and Heparin flushes should have been stored in the medication room.
Manufacturer's Instructions for Tubersol, dated November 1, 2021, indicated that a multi-dose vial of Tubersol solution should be discarded 30 days after it is opened.
Manufacturer's Instructions for Latanoprost, dated August 2011, indicated that once a bottle is opened for use, it may be stored at room temperature for six weeks.
Physician's orders for Resident 7, dated August 3, 2022 included an order for the resident to receive 1 drop of Latanoprost Solution 0.005 percent in both eyes at bedtime.
Observations in the facility's medication room refrigerator on February 8, 2023, at 8:15 a.m. revealed one opened and undated bottle of Latanoprost ophthalmic solution for Resident 7 and one opened and undated bottle of Tubersol Tuberculin injection for Mantoux TB skin test (to test for tuberculosis).
Interview with the ADON on February 8, 2023, at 8:15 a.m. confirmed that the Latanoprost and Tubersol bottles were not labeled with the date they were opened according to manufacturer's instructions.
Manufacturer's instructions for Humalog/lispro insulin, dated December 2022, revealed that the insulin pen was to be discarded 28 days after it was opened.
Manufacturer's instructions for Novolog insulin, dated October 2021, revealed that the insulin pen was to be discarded 28 days after it was opened.
Physician's orders for Resident 20, dated February 2, 2023, included an order for the Resident to receive Lispro insulin three times per day.
Physcian's orders for Resident 41, dated February 7, 2023, included an order for the resident to receive Novolog insulin four times a day.
Physican's orders for Resident 48, dated October 31, 2022, included an order for the resident to receive Levemir insulin two times per day.
Physician's orders for Resident 87, dated February 2, 2023, included an order for the resident to receive Humalog insulin three times per day.
Observations of the C Wing medication cart on February 8, 2023 at 8:10 a.m. revealed that an insulin pen for Resident 87 was open and undated.
An interview with Licensed Practical Nurse 5 on February 8, 2023 at 8:50 a.m. confirmed that the insulin pens were not dated when they were opened to indicate the date they expire and should have been.
Observations of the A wing mediation cart on February 8, 2023, at 8:35 a.m. revealed that an insulin pen for Resident 48 was opened and undated, an insulin pen for Resident 41 was opened and undated, and an insulin pen for Resident 20 was opened and undated.
Interview with Licensed Practical Nurse 6 on February 8, 2023, at 8:35 a.m. confirmed that the insulin pens were not dated when they were opened to indicate the date they expire and should have been.
Interview with the Director of Nursing on February 8, 2023, at 8:48 a.m. confirmed that all insulin pens were to be labeled with the dates that they were opened and discarded in accordance with manufacturer's instructions.
28 Pa. Code 211.9(h) Pharmacy services.
28 Pa. Code 211.12(d)(1) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on review of policies, interviews with residents and staff, and observations, it was determined that the facility failed to serve food that was palatable and at proper temperatures.
Findings inc...
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Based on review of policies, interviews with residents and staff, and observations, it was determined that the facility failed to serve food that was palatable and at proper temperatures.
Findings include:
The facility's policy regarding food temperatures, dated September 30, 2022, revealed that the point of service temperature to residents would be within the range of 120-140 degrees Fahrenheit (F) based on the resident's preference.
Upon interview with Residents 58 and 73 on February 6, 2023, at 9:09 a.m. and 12:07 p.m., the residents stated that the food was absolutely horrible and was not warm.
Upon interview with Residents 45 and 77 on February 6, 2022, at 11:42 a.m. and 11:20 a.m., the residents stated that the food sucked, was terrible, tasteless, and there was nothing good about it.
An interview with a group of residents on February 7, 2023, at 12:58 p.m. revealed that the food was bland and not hot.
Observations in the kitchen on February 7, 2023, at 12:16 p.m. revealed that a test tray was placed on the lunch meal cart going to the A wing. The cart arrived on the unit at 12:18 p.m., and the last resident was served and eating at 12:21 p.m. At 12:21 p.m. the temperature of the mashed potatoes were 108 degrees F, were not hot to taste, and were not palatable at that temperature.
Interview with the Dietary Manager on February 7, 2023, at 12:48 p.m. revealed that the mashed potatoes should have been served at a higher temperature.
28 Pa. Code 201.18(b)(1)(3)(e)(1) 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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and serve food under sanitary conditions, failed to ensure that ...
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Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and serve food under sanitary conditions, failed to ensure that ice was made and stored in sanitary ice machines for one of two ice machines (main kitchen), and failed to ensure that dietary staff wore appropriate hair coverings.
Findings include:
The facility's policy for food receiving and storage, dated September 30, 2022, revealed that all foods stored in the refrigerator or freezer were to be covered, labeled, and dated (use by date).
Observations in the walk-in freezer on February 6, 2023, at 8:21 a.m. revealed that eight bowls of ice cream were on a tray and not dated or labeled, a previously opened box of hamburgers were open to air and not labeled with the date they were opened, and previously opened bags of fish and chicken patties were not labeled with the date that they were opened.
Interview with the Dietary Worker 7 on February 6, 2023, at 8:38 a.m. confirmed that staff should have labeled and dated the bowls of ice cream and dated the above items after opening them.
The facility's policy for ice machines and ice storage chests, dated September 30, 2022, revealed that ice machines and ice storage/distribution containers would be used and maintained to ensure a safe and sanitary supply of ice.
Observations on February 6, 2023, at 8:21 a.m. revealed that there was a blackish tan, removable build up on the top plastic piece and was dripping water onto the ice.
Interview with Dietary Worker 7 on February 6, 2023, at 8:38 a.m. confirmed that the ice machine needed cleaned.
Interview with the Director of Maintenance on February 8, 2023, at 8:21 a.m. revealed that the ice machines were cleaned quarterly but should be cleaned monthly since they can get pretty bad.
The facility's policy regarding staff attire, dated September 30, 2022, revealed that all employees were to wear approved attire for the performance of their duties, were to have their hair off the shoulders and confined in a hair net or cap, and have facial hair properly restrained.
Observations in the main kitchen during service for the lunch meal on February 7, 2023, at 11:56 a.m. revealed that Dietary Worker 8 was assisting with the tray line and placing items on the trays. She had a baseball cap on and her hair was sticking out of the front and sides of the baseball cap.
Interview with the Dietary Manager on February 7, 2023, at 12:48 p.m. confirmed that Dietary Worker 8 should have had her hair covered when working around food in the kitchen.
28 Pa. Code 211.6(f) Dietary services.
28 Pa. Code 207.4 Ice containers and storage.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Concerns
- • 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (40/100). Below average facility with significant concerns.
Bottom line: Trust Score of 40/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Richland Nursing And Rehab's CMS Rating?
CMS assigns RICHLAND NURSING AND REHAB 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 Richland Nursing And Rehab Staffed?
Staff turnover is 49%, compared to the Pennsylvania average of 46%.
What Have Inspectors Found at Richland Nursing And Rehab?
State health inspectors documented 44 deficiencies at RICHLAND NURSING AND REHAB during 2023 to 2025. These included: 44 with potential for harm.
Who Owns and Operates Richland Nursing And Rehab?
RICHLAND NURSING AND REHAB 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 VALLEY WEST HEALTH, a chain that manages multiple nursing homes. With 97 certified beds and approximately 0 residents (about 0% occupancy), it is a smaller facility located in JOHNSTOWN, Pennsylvania.
How Does Richland Nursing And Rehab Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, RICHLAND NURSING AND REHAB's overall rating (1 stars) is below the state average of 3.0, staff turnover (49%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Richland Nursing And Rehab?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Richland Nursing And Rehab Safe?
Based on CMS inspection data, RICHLAND NURSING AND REHAB has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Richland Nursing And Rehab Stick Around?
RICHLAND NURSING AND REHAB has a staff turnover rate of 49%, which is about average for Pennsylvania nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Richland Nursing And Rehab Ever Fined?
RICHLAND NURSING AND REHAB has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Richland Nursing And Rehab on Any Federal Watch List?
RICHLAND NURSING AND REHAB 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.