BROOKLINE NURSING AND REHAB
For profit - Partnership
85 Beds
Independent
Data: November 2025
Trust Grade
60/100
#265 of 653 in PA
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Brookline Nursing and Rehab has a Trust Grade of C+, indicating it is slightly above average and decent for a nursing home. It ranks #265 out of 653 facilities in Pennsylvania, placing it in the top half, and #2 out of 3 in Juniata County, meaning only one local option is better. However, the facility is experiencing a worsening trend, with issues increasing from 9 in 2024 to 10 in 2025. Staffing is a mixed bag, receiving a 3/5 rating with a turnover rate of 44%, which is below the state average, suggesting some staff stability, but average RN coverage may limit specialized care. Notably, the facility has no fines on record, which is a positive sign, but there are concerning incidents, such as the failure to create individualized care plans for residents with dementia and issues with food storage and hygiene in the kitchen, which could impact residents' health and safety.
- Trust Score
- C+
- In Pennsylvania
- #265/653
- Safety Record
- Low Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 44% turnover. Near Pennsylvania's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ○ Average
- Each resident gets 31 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 40%
No red flags
9 → 10 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 10 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below Pennsylvania average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Pennsylvania average (3.0)
Meets federal standards, typical of most facilities
Staff Turnover: 44%
Near Pennsylvania avg (46%)
Typical for the industry
The Ugly 31 deficiencies on record
Mar 2025
10 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident and staff interview, it was determined that the facility failed to provide a reasonable accomm...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and resident and staff interview, it was determined that the facility failed to provide a reasonable accommodation of needs in response to call bell activations for one of two nursing units observed (Unit 2; Residents 14 and 57).
Findings include:
Clinical record review for Resident 57 revealed a diagnosis list that included dementia (a loss of cognitive function that is caused by the permanent damage or death of the brain's nerve cells, or neurons). Resident 57's annual Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated January 14, 2025, noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 15, which indicated no cognitive impairment.
An interview with Resident 57 on March 18, 2025, at 11:31 AM revealed he was sitting in a chair next to the bed. The resident reported concerns that staff do not answer the call bell activations timely and sometimes take an hour or longer to respond and this occurs all the time.
Clinical record review for Resident 14 (Resident 57's roommate) revealed a significant change MDS dated [DATE], that noted a BIMS of 13.
Nursing documentation for Resident 14 dated March 9, 2025, at 1:31 PM revealed Resident noted with cognitive decline.
An attempted interview with Resident 14 on March 18, 2025, at 11:40 AM revealed the resident was asleep and unable to be interviewed.
An interview with the Nursing Home Administrator and Director of Nursing on March 20, 2025, at 2:00 PM revealed the facility can review call bell logs; however, the logs are not specific to the resident and account for the entire room.
A review of the facility documentation titled Room Event Report, for Residents 14 and 57 revealed the following call bell activation dates/times with an elapsed time greater than 20 minutes:
March 7, 2025, at 2:16 PM; elapsed time 20 minutes, 33 seconds
March 8, 2025, at 8:14 PM; elapsed time one hour, 16 minutes, 48 seconds
March 9, 2025, at 10:14 AM; elapsed time 47 minutes, 55 seconds
March 9, 2025, at 11:08 AM; elapsed time 23 minutes, eight seconds
March 9, 2025, at 7:25 PM; elapsed time 29 minutes, 15 seconds
March 9, 2025, at 8:25 PM; elapsed time 54 minutes, 46 seconds
March 10, 2025, at 5:23 AM; elapsed time 20 minutes, 24 seconds
March 10, 2025, at 9:28 AM; elapsed time 46 minutes, 15 seconds
March 10, 2025, at 10:42 AM; elapsed time 52 minutes, 29 seconds
March 10, 2025, at 12:44 PM; elapsed time one hour, eight minutes, 53 seconds
March 11, 2025, at 5:29 PM; elapsed time 38 minutes and 27 seconds
March 12, 2025, at 6:03 AM; elapsed time one hour, 11 minutes, 52 seconds
March 12, 2025, at 8:35 AM; elapsed time one hour, nine minutes, seven seconds
March 13, 2025, at 6:17 AM; elapsed time 44 minutes and 59 seconds
March 13, 2025, at 9:54 AM; elapsed time one hour, 40 minutes, three seconds
March 13, 2025, at 8:15 PM; elapsed time one hour, 12 minutes, 32 seconds
March 14, 2025, at 8:52 AM; elapsed time one hour, 28 minutes, 29 seconds
March 14, 2025, at 4:54 PM; elapsed time 21 minutes, 43 seconds
March 15, 2025, at 12:35 PM; elapsed time one hour, 41 minutes, 26 seconds
March 15, 2025, at 6:19 PM; elapsed time one hour, 34 minutes, 35 seconds
March 15, 2025, at 8:02 PM; elapsed time 41 minutes, 31 seconds
March 16, 2025, at 6:35 AM; elapsed time 23 minutes, and five seconds
March 16, 2025, at 8:38 AM; elapsed time 23 minutes, 13 seconds
March 16, 2025, at 10:46 AM; elapsed time 33 minutes, 44 seconds
March 16, 2025, at 1:10 PM; elapsed time one hour, 27 minutes, six seconds
March 16, 2025, at 6:36 PM; elapsed time 30 minutes, two seconds
March 16, 2025, at 7:30 PM; elapsed time 51 minutes, 21 seconds
March 17, 2025, at 8:58 AM; elapsed time 24 minutes, 23 seconds
March 19, 2025, at 11:43 AM; elapsed time 20 minutes, 41 seconds
March 19, 2025, at 6:15 PM; elapsed time 28 minutes, 16 seconds
An interview with the Nursing Home Administrator and Director of Nursing during a meeting on March 21, 2025, at 10:45 AM revealed the facility was unable to provide an explanation for the extended call bell times as noted in the resident interview and on the Room Event Report.
A follow-up interview with Resident 57 on March 21, 2025, at 10:59 AM reiterated the extended wait time when he sometimes rings the call bell. The resident further noted he sometimes rings the call bell for Resident 14 (the roommate) since that resident has been confused recently. Another attempted interview with Resident 14 revealed that the resident was not interviewable due to confusion.
The facility failed to provide a reasonable accommodation of needs in response to call bell activations for Residents 14 and 57.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on one o...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on one of two nursing units (Unit 3; Residents 51 and 73).
Findings include:
Observation of the Unit 3 Nursing Unit on the following dates and times revealed the following:
On March 18, 2025, at 1:54 PM the drywall was marred behind Resident 51's head of the bed and their recliner.
On March 18, 2025, at 2:24 PM the drywall was marred behind Resident 73's head of the bed.
The above information was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on March 20, 2025, at 2:00 PM.
28 Pa. Code 201.18(b)(3) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold ...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility bed hold policy at the time of transfer for two of five residents reviewed for hospitalizations (Residents 11 and 70).
Findings include:
Clinical record review revealed that Resident 11 was transferred to the hospital on March 17, 2025, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital.
The above information was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on March 21, 2025, at 9:10 AM.
Clinical record review revealed that Resident 70 was transferred to the hospital on March 5, 2025, after she had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and the resident's responsible party upon transfer out to the hospital.
The above information for Resident 70 was reviewed during an interview with the Nursing Home Administrator and the Director of Nursing on March 21, 2025, at 10:24 AM. They confirmed the facility had no further documentation indicating Resident 70's representative received written notice of the facility bed hold policy at the time of transfer.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.29(f) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide appropriate treatment and services to promote bladder continence for one of one resident reviewed for incontinence (Resident 31).
Findings include:
The policy entitled Urinary Continence and Incontinence- Assessment and Management, last reviewed on November 16, 2024, indicates as part of the initial and ongoing resident assessments, the nursing staff and physician will screen residents for information related to urinary incontinence. As part of the facility's assessment, nursing staff will seek and document details related to continence (relevant details include voiding patterns, associated pain or discomfort, and types of incontinence). The nursing staff and physician will identify risk factors for becoming incontinent, or for worsening of the resident's current incontinence. The evaluation will include a review for medications that might affect continence. The staff and physician will summarize the individual's continence status. The staff and physician will identify residents with complications of existing incontinence, or who have risk for such complications. The physician and staff will also address treatable causes, or contributing factors related to urinary incontinence. If the resident remains incontinent despite treating transient causes of incontinence, the staff will initiate a toileting plan. The staff will document the results of the toileting trial in the resident's medical record. The staff and physician will evaluate the effectiveness of interventions, and implement additional pertinent interventions as indicated.
Review of Resident 31's clinical record revealed a Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated February 8, 2025, that indicated that the facility assessed him as being frequently incontinent of bladder, and that a urinary toileting program has not been attempted. The facility also assessed Resident 31 using a BIMS (brief interview for mental status) assessment, with a score of 15 (cognitively intact), and as being able to understand others, be understood, and having adequate vision and hearing. The MDS dated [DATE], also indicated that the facility assessed Resident 31 as requiring extensive assistance of two staff for toileting.
There was no documented evidence in Resident 31's clinical record to indicate that the facility's physician or nursing staff assessed Resident 31 to determine the type of urinary incontinence, or to develop an individualized toileting program or plan of care.
Interview with the Nursing Home Administrator and the Director of Nursing on March 21, 2025, at 10:30 AM confirmed the above findings for Resident 31.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store supplemental oxygen equipment per professional standards of practice for one of o...
Read full inspector narrative →
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store supplemental oxygen equipment per professional standards of practice for one of one resident reviewed (Resident 19).
Findings include:
Clinical record review for Resident 19 revealed a diagnosis list that included acute and chronic respiratory failure (a condition that makes it difficult to breathe) with hypercapnia (elevated levels of carbon dioxide in the blood), chronic obstructive pulmonary disease (COPD, a lung disease that causes inflammation and restricted air flow into and out of the lungs), acute and chronic respiratory failure with hypoxia (low oxygen levels in the body), and pulmonary embolism (a blood clot in the lungs).
Current physician orders for Resident 19 revealed an order dated September 17, 2024, for supplemental oxygen at five liters per minute (LPM) via nasal cannula (medical tubing that delivers supplemental oxygen to the nose) every shift to maintain pulse ox (pulse oximeter; a non-invasive measure of the body's oxygen level) greater than 90 percent.
A review of the current care plan for Resident 19 revealed the resident is at risk for respiratory impairment due to the medical history.
Observation of a wheelchair outside of Resident 19's room on March 18, 2025, at 1:02 PM and 2:25 PM; and March 19, 2025, at 12:10 PM revealed a nasal cannula attached to a portable supplemental oxygen cylinder. The nasal cannula was stuffed into the back canvas storage area of the backrest of the wheelchair. There were also two footrests for the wheelchair in this storage area. The nasal cannula tubing was not protected from contamination from the ambient environment or the footrests in the same storage compartment.
An interview with Employee 5, registered nurse unit manager, on March 19, 2025, at 12:10 PM revealed the wheelchair belonged to Resident 19 and the findings were reviewed with Employee 5.
The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on March 19, 2025, at 1:45 PM.
483.25(i) Respiratory/tracheostomy Care and Suctioning
Previously cited deficiency 3/22/24
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess for the risk of side rail entrapment for one of three residents reviewed for acc...
Read full inspector narrative →
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to assess for the risk of side rail entrapment for one of three residents reviewed for accident hazards (Resident 72).
Findings include:
Observation of Resident 72's room on March 18, 2025, at 2:02 PM revealed that there was a left one-quarter side rail observed on the bed.
Clinical record review for Resident 72 revealed that the facility completed a side rail assessment, review of potential risks, and obtained consent on February 7, 2025. The facility also completed a side rail entrapment evaluation on February 7, 2025, which revealed that the facility assessed zone six (between the end of the enabler device and the side of the headboard). There was no documentation that the facility assessed the risk for entrapment posed in zones one (within the rail), two (between the bottom of the rail and top of compressed mattress), three (between the edge of the mattress and inside of the rail, and four (between the top of the compressed mattress and the bottom of the rail at the end of the rail).
The above information was reviewed during an interview with the Nursing Home Director and the Director of Nursing on March 20, 2025, at 2:00 PM.
28 Pa. Code 211.12 (d)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by three of three residents reviewed (Residents 18, 55, and 61).
Findings include:
Clinical record review for Resident 18 revealed the facility admitted him on July 13, 2018. A diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life) was added on October 3, 2022. A review of Resident 18's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated February 9, 2025, indicated that the facility assessed Resident 18 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.
A review of Resident 18's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.
Clinical record review for Resident 55 revealed that the facility admitted her on May 15, 2022, with diagnoses including dementia. A review of Resident 55's most recent annual MDS dated [DATE], indicated that the facility assessed Resident 55 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.
A review of Resident 55's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.
Clinical record review for Resident 61 revealed that the facility admitted her on May 27, 2023, with a dementia diagnosis added May 31, 2023. A review of Resident 61's most recent annual MDS dated [DATE], indicated that the facility assessed Resident 61 as having a diagnosis of dementia. The facility determined that a care plan for dementia and cognitive loss would be developed.
A review of Resident 61's care plan revealed that there was no indication that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.
These findings were reviewed with the Nursing Home Administrator and Director of Nursing during a meeting on March 20, 2025, at 2:00 PM for Residents 18, 55, and 61.
28 Pa Code 211.12 (d)(1)(3)(5) Nursing services
28 Pa Code 211.11(d) Resident care plan
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food ite...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to store food items in a safe and sanitary manner, maintain equipment in a sanitary condition, and prepare food items in accordance with professional standards in the facility's main kitchen.
Findings include:
Initial tour of the facility's main kitchen with Employee 4, Dietary Manager, on March 18, 2025, at 10:00 AM revealed the following:
There was a large hole observed in the wall of the dishwashing area. Two wall tiles adjacent to the hole had fallen off the wall onto the ground.
There was an extensive build-up of dust on the appliance that Employee 4 referred to as the air handler.
A wall-mounted first aid kit held burn spray that expired in 2021 and eye wash that expired in 2023.
A smaller pantry area located in the hallway outside of the main kitchen held hand wipes that expired in October 2023.
The pantry area also held a bottled drink that Employee 4 reported was used for colonoscopy (an exam where a flexible medical device is inserted into the colon to assess for abnormalities) preps. This drink was being stored in the same area as commercial sanitizer/cleaner.
A review of the food temperature logs for February 2025, with Employee 4 on March 20, 2025, at 11:50 AM revealed the dates of February 19 and 26 had no dinner food temperatures documented as assessed by kitchen staff.
The findings were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on March 20, 2025, at 2:00 PM.
28 Pa. Code 201.14(a) Responsibility of licensee
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on review of employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of ...
Read full inspector narrative →
Based on review of employee education records and staff interview, it was determined that the facility failed to ensure that nurse aides received 12 hours of in-service training annually for three of three nurse aides reviewed (Employees 1, 2, and 3).
Findings include:
During a meeting with the Nursing Home Administrator and Director of Nursing on March 20, 2025, at 2:00 PM the surveyor asked for training records to indicate that nurse aides had received at least 12 hours of in-service training in the last year for Employees 1, 2, and 3 (nurse aides).
Interview with the Nursing Home Administrator and Director of Nursing on March 21, 2025, at 10:55 AM confirmed there was no documented evidence that the above employees received the required 12 hours of annual in-service training.
28 Pa. Code 201.19 (7) Personnel policies and procedures
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or thei...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident and/or their responsible party in writing of a transfer to the hospital with the required information for four of five residents reviewed (Residents 11, 39, 48, and 70).
Findings include:
Clinical record review for Resident 11 revealed that they were transferred to the hospital on March 17, 2025, after a change in their condition. There was no documentation that the facility provided written notification to the resident or the resident's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred, a statement of the resident's right to appeal, including the name, contact, email, and address, how to obtain and appeal form, assistance completing and submitting the appeal form and hearing request, and contact, email, and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.
The above information was reviewed during an interview with the Nursing Home Administrator and Director of Nursing on March 21, 2025, at 9:10 AM.
Clinical record review for Resident 39 revealed she was transferred to the hospital from [DATE] to 31, 2025, January 10 to 21, 2025, and December 9 to 16, 2024. There was no evidence to indicate that Resident 39's responsible party was provided written notification to include the above-required contents.
Clinical record review for Resident 48 revealed that he was transferred to the hospital from [DATE] to 7, 2025. There was no evidence to indicate that Resident 48's responsible party was provided written notification to include the above-required contents.
Clinical record review for Resident 70 revealed she was transferred to the hospital from [DATE] to 7, 2025. There was no evidence to indicate that Resident 70's responsible party was provided written notification to include the above-required contents.
The Nursing Home Administrator and the Director of Nursing confirmed the above noted findings regarding transfer notices for Residents 39, 48, and 70 during an interview on March 21, 2025, at 10:24 AM.
28 Pa. Code 201.14 (a) Responsibility of license
28 Pa. Code 201.29(a) Resident rights
Mar 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to establish clear and consisten...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to establish clear and consistent resident's wishes regarding advance directives for two of three residents reviewed (Residents 26 and 32).
Findings include:
Review of Resident 32's clinical record revealed that the facility admitted her on February 11, 2024. Review of a POLST (Physician Orders for Life Sustaining Treatment, a document for specific medical orders to be honored by health care workers during a medical crisis) form signed by Resident 32's responsible party on February 13, 2024, indicated that he wished for Resident 32 to have full treatment, including CPR (cardiopulmonary resuscitation).
A physician's order dated February 14, 2024, indicated that Resident 32 was a DNR (Do Not Resuscitate, not to perform cardiopulmonary resuscitation if breathing stops). There was no documented evidence in Resident 32's clinical record to indicate she or her responsible party's advance directive (written instruction, such as a living will or durable power of attorney, relating to the provision of healthcare, for a time when a resident may be incapacitated and not able to make decisions) wishes changed.
Resident 32 continued to be a DNR until [DATE], when the facility identified the issue during the on-site survey and corrected the physician's order.
Interview with the Director of Nursing on [DATE], at 10:45 AM confirmed the above findings for Resident 32.
Review of Resident 26's electronic clinical record revealed an active physician's order dated [DATE], that instructed staff to provide full code treatment. The order included that there were no directions specified for the order.
Review of a POLST initialed by Resident 26's physician (with an indecipherable date of signature) and signed by Resident 26's son, indicated treatment wishes included full code treatment; however, limited interventions to refuse intubation (DNI, do not insert a tube into the airway to help with breathing). The registered nurse signed this document on February 16, 2019.
The surveyor reviewed the DNI omission from Resident 26's electronic physician orders during an interview with the Director of Nursing and the Nursing Home Administrator on [DATE], at 2:00 PM.
Resident 26's physician order was revised on [DATE] (following the surveyor's questioning) to, Full Code - DNI.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.29(a) Resident rights
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 observation, clinical record review, review of facility documentation, and staff and a resident's family interview, it was determined that the facility failed to implement interventions to pr...
Read full inspector narrative →
Based on observation, clinical record review, review of facility documentation, and staff and a resident's family interview, it was determined that the facility failed to implement interventions to prevent falls and/or injuries for one of seven residents reviewed for falls (Resident 57) and failed to prevent a potential accident hazard at the facility's main entrance.
Findings include:
Clinical record review for Resident 57 revealed a current physician's order for staff to apply a sensor pad alarm to her chair and check the placement and function every shift for safety.
Observation of Resident 57 on March 19, 2024, at 12:38 PM and March 20, 2024, at 12:10 PM
revealed that she was in her recliner and her chair alarm was placed on her wheelchair:
Concurrent interviews during each date and time with Resident 57's family confirmed the observations.
Review of the facility's after-hours entrance procedure indicated that the front main entrance door is open from 5:00 AM to 9:00 PM.
Observation of the front main entrance lobby on March 22, 2024, at 8:40 AM revealed no staff within visualization of the front doors; and the doors were unsecured. Resident rooms and a main dining room were within visualization of the front lobby.
Interview with the Nursing Home Administrator on March 22, 2024, at 8:42 AM confirmed that the facility did not have a receptionist or staff assigned to monitor the unsecured front doors that led from the main lobby to the main parking lot and public road. Should a resident (who was not previously identified as an elopement risk) become acutely confused or agitated, that resident could exit the facility through the main door without staff knowledge between the hours of 5:00 AM and 9:00 PM unless staff happened to be in the area.
Interview with the Nursing Home Administrator and the Director of Nursing on March 22, 2024, at 12:30 PM indicated that, following the surveyor's questioning, the facility practice would be to have a staff member present in the lobby when the doors are not secured.
483.25(d)(1)(2) Free Of Accident Hazards/supervision/devices
Previously cited 4/21/23
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to administer supplemental oxygen as prescribed by the physician for one of one resident r...
Read full inspector narrative →
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to administer supplemental oxygen as prescribed by the physician for one of one resident reviewed for oxygen concerns (Resident 27).
Findings include:
Clinical record review for Resident 27 revealed an active physician's order dated January 12, 2023, that instructed staff to administer supplement oxygen via a nasal cannula (NC, flexible tubing with small prongs at one end inserted into the nostrils for the application of supplemental oxygen) at three liters per minute (3 l/m).
Observation of Resident 27 on March 19, 2024, at 1:37 PM revealed the application of supplemental oxygen via a NC and room oxygen concentrator (medical device used to concentrate the oxygen available in room air to administer oxygen-enriched supply back to the resident). The administration setting on the room concentrator was two liters per minute (2 l/m).
Observation of Resident 27 on March 21, 2024, at 3:02 PM again revealed the application of supplemental oxygen via a NC and room concentrator at a rate of 2 l/m. Interview with Employee 2 (nurse aide) on the date and time of the observation confirmed the concentrator setting of 2 l/m.
Observation of Resident 27 on March 21, 2024, at 3:21 PM with Employee 3 (licensed practical nurse) confirmed the oxygen concentrator setting of 2 l/m when the current physician orders instructed staff to administer the supplemental oxygen at 3 l/m.
483.25(i) Respiratory/tracheostomy Care and Suctioning
Previously cited deficiency 4/21/23
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to ensure necessary behavioral health treatments were initiated for one of one resident reviewed (Reside...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to ensure necessary behavioral health treatments were initiated for one of one resident reviewed (Resident 64).
Findings include:
Review of Resident 64's clinical record from August 9, 2023, until October 24, 2023, revealed multiple documented behaviors including holding on to a females arm tightly and rubbing it, rubbing females backs, pulling fire alarms, cornering females, and not letting them pass, inappropriate sexual behaviors, wanting females to sit on his lap, and following females around the facility.
Review of a psychiatric evaluation dated October 24, 2023, indicated a new order for Resident 64 to start Prozac (used to treat some mood disorders) 10 mg (milligrams) every day. The new order for Prozac was noted by nursing staff on October 30, 2023, but never added to Resident 64's medication regimen until November 23, 2023, a month after it was ordered.
Interview with the Director of Nursing on March 21, 2024, at 2:15 PM, confirmed the above findings for Resident 64.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Resident 45).
Findings includ...
Read full inspector narrative →
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate of less than five percent (Resident 45).
Findings include:
The facility's medication error rate was 5.56 percent based on 36 medication opportunities with two medication errors.
Observation of Resident 45's medication administration pass on March 22, 2024, at 9:15 AM revealed Employee 1, licensed practical nurse, prepared the resident's medications prior to administration. Employee 1 proceeded to open the medication capsules and pour the contents into a medication administration cup. Employee 1 mixed the contents with applesauce and then administered the medications to the resident.
Clinical record review for Resident 45 revealed a current physician's order to administer Tolterodine Tartrate ER (extended release) capsule (a medication used to treat an overactive bladder) 4 milligrams one time a day. The instructions on the medication package provided by the pharmacy instructed to swallow whole and do not crush or chew.
An interview with Employee 1 on March 22, 2024, at 10:00 AM confirmed she opened the capsule prior to administration.
Clinical record review for Resident 45 revealed a current physician's order to administer Trelegy Ellipta Inhalation Aerosol Powder Breath Activated (a medication used to treat certain breathing disorders) 100-62.5-25 micrograms/activation (Fluticasone-Umeclidinium-Vilanterol); administer one puff and inhale orally one time a day. The order instructed to rinse the mouth with water and spit after use.
A review of the manufacturer's instructions for the Trelegy offers step by step directions on use that instructed to, Rinse your mouth with water after you have used the inhaler and spit the water out. Do not swallow the water.
Employee 1 administered the Trelegy inhaler to Resident 45 and immediately after administration the resident took a drink and swallowed the liquid. Employee 1 then administered the remaining resident medications. The resident did not rinse her mouth with water and spit after use of the inhaler as the physician order directed immediately following administration of the inhaler.
The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on March 22, 2023, at 12:35 PM.
28 Pa. Code 211.9(a)(1) Pharmacy services
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0813
(Tag F0813)
Could have caused harm · This affected 1 resident
Based on review of select facility policies, observations, and staff and resident family interviews, it was determined that the facility failed to ensure safe and sanitary storage and handling of pers...
Read full inspector narrative →
Based on review of select facility policies, observations, and staff and resident family interviews, it was determined that the facility failed to ensure safe and sanitary storage and handling of personal food products brought in from outside sources for one of two nursing units. (200 Nursing Unit, Resident 57).
Findings Include:
Review of Facility Policy: Foods Brought by Family/Visitors, last reviewed without changes on November 17, 2023, revealed that the facility will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. Facility staff will discard perishable foods on or before the use by date. Nursing and/or food service staff will discard any food any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates).
Observation of Resident 57's room on March 19, 2024, at 12:39 PM revealed that she had a personal refrigerator. The temperature monitoring log was dated April 2023, and completed through April 21, 2023. There was no current temperature monitoring log for Resident 57's refrigerator. Inside Resident 57's refrigerator was a bottle of opened ranch dressing with a use by date of November 24, 2022, two cartons of single serve lemonade with a use by date of March 15, 2024, and a single serve cheese stick with a use by date of July 26, 2023. Inside Resident 57's freezer area of the refrigerator there was 1.5 inches of ice incasing two single serve containers of ice cream with an unknown use by date due to being unable to remove them from the freezer area. On top of Resident 57's refrigerator there were two undated squares of homemade peanut butter fudge that was dried and hard. Resident 57's family member confirmed the observation.
Observation of Resident 57's refrigerator on March 22, 2024, at 9:34 AM with the Director of Nursing (DON) revealed that there was an open container of butter with a use by date of September 28, 2023. On Resident 57's wheelchair there was a container of snacks including a bag of peanuts with a use by date of July 23, 2023. The DON confirmed the observations.
28 Pa. Code 201.18(b)(1) Management
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to initiate their abuse policy and thoroughly investigate inc...
Read full inspector narrative →
Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to initiate their abuse policy and thoroughly investigate incidents to rule out the potential for abuse for one of two residents reviewed (Resident 64).
Findings include:
The policy entitled Abuse Investigation and Reporting, last reviewed on November 17, 2023, indicates that if an incident, suspected incident, or resident abuse is reported, the Administrator will assign the investigation to an appropriate individual. The individual conducting the investigation will review the residents medical record to determine events leading up to the incident, interview the person reporting the incident, and interview any witnesses to the incident. Witness reports will be obtained in writing. Either the witness will write his or her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him or her sign and date it.
Review of Resident 64's clinical record revealed nursing documentation dated January 4, 2024, at 10:11 PM that indicated Resident 64 rubbed a female residents butt two times. Nursing staff told him not to do that, and Resident 64 was noted to look at staff and laugh.
Interview with Employee 3, licensed practical nurse, on March 21, 2024, at 1:49 PM revealed that she was the nurse who wrote the documentation about Resident 64 on January 4, 2024. Employee 3 indicated that she was not the staff member who witnessed the event. There was no documented evidence that the facility interviewed the staff member who witnessed the event, nor obtained a signed statement. There was no evidence to indicate the facility completed a thorough investigation to rule out resident to resident sexual abuse.
Nursing documentation dated February 23, 2024, at 2:54 PM indicated that Resident 64 was found holding on to a females arm and mouth kissing her. The nursing documentation then indicated that a few moments later Resident 64 was blocking the same female from leaving her bathroom.
Interview with Employee 3 on March 21, 2024, at 1:49 PM revealed that she was the nurse who wrote the documentation about Resident 64 on February 23, 2024. Employee 3 indicated that she was not the staff member who witnessed the event. There was no documented evidence that the facility interviewed the staff member who witnessed the event, nor obtained a signed statement. There was no evidence to indicate the facility completed a thorough investigation to rule out resident to resident sexual abuse.
Interview with the Administrator and Director of Nursing on March 21, 2024, at 2:15 PM acknowledged the above findings for Resident 64.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.29(a)(c) Resident rights
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 clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding bowel protocol medication administration for two of tw...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding bowel protocol medication administration for two of two residents reviewed (Residents 43 and 77) and regarding the use of a cardiac pacemaker for one of one resident reviewed with a pacemaker (Resident 26).
Findings include:
Clinical record review for Resident 43 revealed a current care plan that noted bowel/bladder elimination alteration and constipation related to immobility and medications. Some interventions included: Administer medications per physician order, bowel protocol as needed; report bowel movements and report abnormalities; and report signs and symptoms of constipation such as abdominal cramping, diarrhea, nausea/vomiting, no bowel movement for three days.
Clinical record review for Resident 43 revealed the following physician orders to promote bowel movements:
Milk of Magnesia Suspension 400 mg (milligrams) per 5 ml (milliliters) (MOM, laxative that pulls water into bowel to soften bowel contents) Give 30 ml by mouth as needed (PRN) and administer if no bowel movement by the third day (nine shifts) and document effectiveness.
Dulcolax suppository (Bisacodyl, a laxative medication used to relieve constipation) insert one suppository rectally as needed for constipation for no bowel movement within 24 hours after administration of Milk of Magnesia.
Fleet's Enema 7-19 gm (grams) per 118 ml (Sodium Phosphates, liquid medication inserted into the rectum to treat constipation) Insert 1 applicatorful rectally for no bowel movement by the end of the following shift after administration of suppository.
Review of bowel elimination records for Resident 43 revealed that staff documented no bowel movements for February 20, 21, 22, 23, and 24, 2024.
There was no indication that staff offered (as per the physician orders and bowel management protocol), or Resident 43 refused, any PRN medications.
Clinical record review for Resident 77 revealed the following physician orders to promote bowel movements:
Milk of Magnesia Suspension 400 mg per 5 ml, give 30 ml by mouth as needed (PRN) and administer if no bowel movement by the third day (nine shifts) and document effectiveness.
Dulcolax suppository insert one suppository rectally as needed for constipation for no bowel movement within 24 hours after administration of Milk of Magnesia.
Fleet's Enema 7-19 gm per 118 ml, insert 1 applicatorful rectally for no bowel movement by the end of the following shift after administration of suppository. Notify the physician if ineffective.
Review of bowel elimination records for Resident 77 revealed that staff documented no bowel movements for March 3, 4, 5, 6, 7, 8, 9, 2024.
There was no indication that staff offered (as per the physician orders and bowel management protocol), or Resident 77 refused, any PRN medications.
The above information for Residents 43 and 77 was confirmed in a meeting with the Nursing Home Administrator and Director of Nursing on March 22, 2024, at 12:30 PM.
Clinical record review for Resident 26 revealed an active physician order dated March 5, 2024, that indicated Resident 26 had a cardiac pacemaker (medical device implanted in the chest with wires connected to portions of the heart for the purpose of an electrical stimulation of a heartbeat); and that staff were to follow pacemaker checks per the cardiology schedule. There were no additional directions specified for the order.
A plan of care initiated by the facility on February 16, 2019, identified Resident 26 had cardiac disease and required pacemaker checks as ordered.
Neither the plan of care or physician orders stipulated the type of pacemaker, the method of pacemaker checks (e.g., in-person cardiac clinic assessments versus bedside monitoring device, etc.), or emergency procedures to follow in the event of outages of power, cell phone, or internet.
Progress note documentation by the consulting cardiology provider dated May 11, 2023, indicated that Resident 26 had complete heart block (the most serious type of heart block, where there's a complete separation of electrical activity between the upper and lower chambers of the heart; it can be fatal if not treated with a pacemaker or other methods) and a dual chamber pacemaker (connects to both the upper and lower chambers of the heart and regulates the pace of contractions).
The surveyor requested that the facility provide information regarding the type of Resident 26's pacemaker and the method of her pacemaker checks during interviews with the Nursing Home Administrator and the Director of Nursing on March 21, 2024, at 1:45 PM, and March 22, 2024, at 12:20 PM.
Nursing documentation dated March 22, 2024, at 12:48 PM revealed that staff checked Resident 26's room and noted Medtronic pacemaker equipment on her bedside table, plugged in, and functional for automatic pacemaker check transmissions.
Review of the Medtronic MyCareLink Patient Monitor manual provided with Resident 26's equipment indicated that the monitor is designed to automatically gather information from the implanted heart device. The monitor must remain plugged in to a power outlet; and that heart device information is sent to the Medtronic CareLink Network using the cellular phone network. Use of the equipment adjacent to or stacked with other equipment should be avoided because it could result in improper operation (e.g., within 6.5 feet of a television, computer monitor/screen, mobile phones, cordless telephones). When choosing a place to set up the monitor, consider a location that receives adequate cellular signal and near the sleeping area (up to 10 feet away).
Interview with the Director of Nursing on March 22, 2024, at 12:51 PM confirmed that Resident 26 had a pacemaker monitoring machine that performed continuous monitoring that would notify the cardiology office of an arrythmia (abnormal heart rhythm) in real time. The Director of Nursing did not know if the communication between Resident 26, the monitor, and the cardiology office was dependent on Bluetooth technology, Wi-Fi connection, landline telephone service, or cellular telephone service. The interview confirmed that this information was not part of Resident 26's plan of care; therefore, Resident 26's plan of care did not include procedures to follow in the event of utility outages.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected multiple residents
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the appropriate physician ordered enteral nutrition for one of one resident rev...
Read full inspector narrative →
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the appropriate physician ordered enteral nutrition for one of one resident reviewed for tube feeding concerns (Resident 27).
Findings include:
Clinical record review for Resident 27 revealed an active physician's order dated January 14, 2023, that instructed staff to provide enteral feeding (provision of food and fluids via the gastrointestinal tract, e.g., directly into the stomach, not through the mouth) of Isosource 1.5, 65 ml (milliliters) continuously with 250 ml water every six hours. An active physician's order dated January 26, 2023, instructed staff to clear the feeding pump and document the amount given for both water and feeding every shift.
Observation of Resident 27 on March 19, 2024, at 1:29 PM revealed Isosource 1.5 liquid nutrition infusing via a pump set at a rate of 65 ml per hour and a stop setting at 520 ml. A bag of water was also attached to the pump system.
Observation of Resident 27 on March 21, 2024, at 3:21 PM with Employee 3 (licensed practical nurse) verified that Isosource 1.5 liquid nutrition infused at a rate of 65 ml per hour. Employee 3 explained that the pump settings would allow 520 ml of liquid nutrition to infuse and then automatically initiate the water flush until 250 ml of water infused. The pump would then shut off, alarm for staff attention, and staff would reset the liquid nutrition infusion. Employee 3 stated that she typically must clear and reset the pump settings at the beginning of her shift and at the end of her shift (in approximately eight hours). Employee 3 confirmed that 520 ml of liquid nutrition would not infuse until eight hours have elapsed (65 ml for eight hours equaled 520 ml); therefore, the automatic flush would not initiate until eight hours have elapsed. Employee 3 verified that the active physician orders for Resident 27 instruct staff to ensure that he received 250 ml of water every six hours.
Clinical record review for Resident 27 revealed a revision dated March 21, 2024 (following the surveyor's questioning) that changed the active physician order for Resident 27's enteral feeding to now instruct staff to clear the feeding pump and document the amount given for both water and feeding every shift; infuse Isosource at 390 ml every six hours (65 ml for six hours equaled 390 ml) and water at 250 ml every six hours.
Review of Resident 27's treatment administration record (TAR, electronic documentation of the provision of treatments) dated March 2024 revealed that staff documented that they provided 520 ml of feeding and 250 ml of water every shift (three times a day) from March 1, 2024, through the first shift of March 21, 2024. Staff began to document 390 ml of feeding and 250 ml of water on the evening shift of March 21, 2024.
The facility failed to provide evidence that Resident 27 received 250 ml of water every six hours per the physician's order until after the surveyor's questioning.
28 Pa. Code 211.12(d)(1)(5) Nursing services
Apr 2023
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to refer a resident with a newly diagnosed mental disorder for level II review for one of one resident r...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to refer a resident with a newly diagnosed mental disorder for level II review for one of one resident reviewed for PASRR (Pre-admission Screening and Resident Review) compliance (Resident 30).
Findings include:
The PA-PASRR-ID form (Pennsylvania Pre-admission Screening and Resident Review; PA-PASRR, federally required form to help ensure that all individuals are evaluated for serious mental disorder and/or intellectual disability to ensure applicants are not inappropriately placed in nursing homes for long term care) dated February 2016 and revised in September 2018, lists examples of serious mental illness including psychotic disorder, and schizophrenia.
The revised PA-PASRR-ID bulletin number 01-14-13, 03-14-10, 07-14-01, 55-14-01 dated March 1, 2014, revealed that nursing facilities are responsible for assuring the accuracy of information reported on the PA-PASRR-ID form. If the individual has a change in condition that affects target status a PA-PASRR-EV (Level II) will need to be completed. Nursing facilities will communicate the need to have a PA-PASRR-EV done by notifying the Department's (Department of Public Welfare, now the Department of Human Services) Office of Long-Term Living, Bureau of Quality and Provider Management, Division of Nursing Facility Field Operations via the MA 408 form (a form used to notify the Department of a change in a resident's target status).
Review of the MA 408 form dated March 2020 indicates that with a change in a resident's condition (any change in the individual's condition that affects the target status) the nursing facility is to send or fax the original form within 48 hours to their (Department of Public Welfare's) nursing facility field operations office.
Review of Resident 30's clinical record revealed a PA-PASARR dated July 13, 2018, that documented no disorders that would trigger a level II review. The assessment indicated that there were no diagnoses of neurocognitive disorders or serious mental illness, a level II review was not necessary, and to admit Resident 30 as a regular admission. The form was reviewed by the Department of Human Services (DHS) on October 4, 2018. Resident 30 was admitted to the facility with a diagnosis of psychotic disorder that was not captured on the PA-PASARR upon his admission.
On February 9, 2023, Resident 30's tele psych nurse practitioner added the diagnosis of schizophrenia to his plan of care. There was no evidence that the facility notified the appropriate agencies regarding Resident 30 upon being diagnosed with a target diagnosis.
Interview with the Administrator on April 20, 2023, at 2:10 PM acknowledged the above findings for Resident 30.
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.16(a) Social services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide activities of daily living assistance for resident's dependent on staff assistan...
Read full inspector narrative →
Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide activities of daily living assistance for resident's dependent on staff assistance for one of three residents reviewed for activity of daily living concerns (Resident 36).
Findings include:
Review of Resident 36's annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 8, 2023, documentation revealed that she required extensive assistance from staff for personal hygiene, which includes brushing of teeth/oral care.
Record review for Resident 36 revealed a nursing progress note dated April 11, 2023, at 10:54 AM that the resident tested positive for COVID-19 (highly infectious respiratory illness). Precautions were implemented per protocol.
Observation of Resident 36 on April 19, 2023, at 11:00 AM revealed the resident was in bed and on TBP (Transmission Based Precautions, special precautions to protect the spread of infection) in a designated room for TBP by the facility. Concurrent interview with Resident 36 revealed that no one helped her with cleaning her teeth. Resident 36 attempted to remove her upper denture and said she was having a hard time removing it. A denture cup and oral care supplies were not found in Resident 36's room. Employee 8, nurse aide, entered the room at 11:05 AM and confirmed there were no supplies in the room to clean the resident's denture or to provide oral care. Employee 8 indicated that sometimes resident supplies don't get moved with residents when moving to a room for TBP.
The above findings for Resident 36 were reviewed with the Nursing Home Administrator and Director of Nursing on April 19, 2023, at 2:15 PM.
483.24(a)(2) ADL Care Provided for Dependent Residents
Previously cited 4/15/22
28 Pa. Code 211.12 (d)(1)(2)(3)(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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to en...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff and resident interview, it was determined that the facility failed to ensure an environment free from potential accident hazards for three of five residents reviewed (Residents 24, 61, and 23).
Findings include:
Review of Resident 24's clinical record revealed nursing documentation dated February 13, 2023, at 10:27 AM that indicated while a nurse aide was transferring Resident 24 from her bed to a shower chair, Resident 24 had to be lowered to the floor because her legs looked week and were giving out. The note also indicated that the shower chair that Resident 24 was being transferred to was in a locked position but still slid backwards.
Review of the facility's investigation into Resident 24's fall on February 13, 2023, also noted that the shower chair slid back even with the wheels in the locked position. The investigation did not contain documented evidence to indicate that the facility checked the shower chair that was used during this incident for malfunction.
Interview with the Administrator and Director of Nursing on April 20, 2023, at 2:10 PM, confirmed the above findings for Resident 24.
Clinical record review for Resident 61 revealed that she was admitted to the facility on [DATE].
Interview with Resident 61 on April 18, 2023, at 12:25 PM revealed the resident was admitted to the facility due to falls and fracturing her ribs. Resident 61 indicated planning to return to her previous living situation. Resident 61 also reporting falling when getting into a car to go out to lunch with her friend.
Review of a self-care deficit care plan for Resident 61 revised on March 28, 2023, revealed the resident may go on a LOA (leave of absence) with a responsible party. In addition, the resident was to have moderate independence with a front wheeled walker in her room.
Review of a fall risk care plan for Resident 61 revised on March 28, 2023, revealed the resident was at risk for falls due to a history of falls with fracture and medication side effects. The staff were to assist with transfers and ambulation as needed.
The care plans for Resident 61 did not stipulate the type of assistance to be provided to Resident 61 when out of her room.
Review of OT (Occupational Therapy) notes for Resident 61 dated April 10, 2023, revealed that the resident inquired about being independent in her room. The OT discussed with PT (Physical Therapist) and PTA (Physical Therapy Assistant), and it was agreed that Resident 61 can be independent in her room. Safety awareness was discussed with Resident 61 for her to use the call bell for assistance when needed despite being independent in her room to decrease risk of falls.
Review of PT notes for Resident 61 dated April 12, 2023, revealed that the resident was a very high risk for falls on April 7, 2024, and was a high risk for falls on April 12, 2023.
Review of facility documentation for Resident 61 revealed the nurse was called outside to the facility parking lot on April 12, 2023, at 12:22 PM. Resident 61 was going on LOA with her friend for lunch and fell getting into the car. The resident was sitting on her bottom next to the open passenger side door and her feet were straight out in front of her, her back was against the car and her left arm was up on door arm rest. The resident sustained a skin tear on the left forearm that measured 6.5 cm (centimeters) x 1 cm. Resident 61 reported that she was trying to get in the car and sat on the car seat but then slid right off onto her hands and knees. Steri-strips (sticky paper bands to hold skin together) were applied to the skin tear after cleansing it. The resident also had an abrasion to the left knee that was cleansed.
Review of the facility's investigation into the above event for Resident 61 revealed an intervention for physical therapy to screen the resident. (Resident 61 was already on active caseload for PT and OT).
Clinical record review of physical therapy and occupational therapy notes from March 27, 2023, through April 18, 2023, revealed no evaluation or instructions on safety related to car transfers prior to Resident's 61 fall or after the fall on April 12, 2023. There was no recommended level of supervision or assistance with ambulation for Resident 61 when outside of her room, i.e., supervision, contact guard, or assistance from staff.
During an interview with Employee 9, occupational therapist, and Employee 11, Director of Therapy on April 20, 2023, at 10:20 AM it was revealed that Resident 61 has poor endurance and that it would have been better if staff took her in a wheelchair to her car as she was fatigued.
During an interview with Employee 10 physical therapist, Employee 8, and the Nursing Home Administrator and Director of Nursing, on April 20, 2023, at 10:37 AM the surveyor questioned why the resident was not accompanied by staff to the car. Employee 10 revealed that Resident 61 participated in OT and PT the morning of her fall. After therapy, the resident went to her room and then her friend came and took her with her walker. She signed out at the nursing station, and the resident and friend took it upon themselves to go out to lunch. Employee 9 indicated that Resident 61's room is at the back of the home and one of the furthest rooms from the facility entrance and the resident was fatigued. It was also confirmed at this time that Resident 61 did not have an evaluation for car transfers prior to the fall knowing that she has a history of falls, and there was no follow up screen from physical therapy regarding the fall.
Clinical record review for Resident 23 revealed a diagnoses list that included a history of falling.
Clinical record review for Resident 23 revealed a current care plan that noted the resident is a risk for falls due to the medical history. An intervention listed in the care plan included a fall mat to the right side of the bed.
A review of the nursing [NAME] (an electronic device that includes pertinent resident information used for care) for Resident 23 instructed staff to check placement and function every shift, and as needed, and this included a fall mat to the right side of the bed.
Observation of Resident 23 on April 19, 2023, at 9:38 AM revealed the resident was in bed. There was no observed fall mat as directed in the care plan.
Observation and concurrent interview with Employee 6, licensed practical nurse, on April 19, 2023, at 11:46 AM confirmed there was no fall mat at Resident 23's bedside.
The above findings for Resident 23 were discussed in a meeting on April 20, 2023, at 2:15 PM with the Nursing Home Administrator and Director of Nursing.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 211.10(d) Resident care policies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store supplemental oxygen equipment per professional standards of practice for three of...
Read full inspector narrative →
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to store supplemental oxygen equipment per professional standards of practice for three of three residents reviewed (Residents 16, 25, and 70).
Findings include:
Clinical record review for Resident 16 revealed a medical history that included Chronic Obstructive Pulmonary Disease (COPD, chronic disease that causes lung inflammation) and Obstructive Sleep Apnea (a sleep-related breathing disorder).
Current physician orders for Resident 16 included to apply BiPAP (Bi-level positive airway pressure that is a non-invasive ventilation machine used to treat various respiratory issues) at bedtime.
Resident 16's current care plan noted the resident has a risk for respiratory impairment and decreased cardiac output related to the medical history. Interventions noted in the care plan included using BiPAP at bedtime.
Observation of Resident 16's oxygen equipment on April 18, 2023, at 12:44 PM and April 19, 2023, at 9:40 AM revealed a BiPAP mask on the bedside dresser top that was not protected from contamination. A gallon container of distilled water was also on the dresser with a quarter amount of liquid in it. The gallon container did not have an open date.
An interview with Employee 6, licensed practical nurse, regarding Resident 16's oxygen equipment confirmed the findings and revealed that the BiPAP mask should be bagged, and the distilled water should be dated.
Clinical record review for Resident 25 revealed a discontinued order for a nebulizer (a device for inhaling certain medications) Ipratropium-Albuterol 0.5-2.5 milligrams (mg) (a type of medication to treat certain respiratory illnesses) per three milliliters (ml) to be inhaled via nebulizer four times a day for 10 days. The order was discontinued on April 11, 2023. There are no additional orders or interventions in the care plan related to oxygen therapy.
Observations on April 18, 2023, at 12:30 PM and April 19, 2023, at 10:03 AM revealed a nebulizer mask on the dresser next to Resident 25's bed. The mask was not protected from contamination and the oxygen tubing was not dated.
An interview and concurrent observation with Employee 6 on April 19, 2023, at 11:46 AM revealed Resident 25's nebulizer mask should be bagged, and oxygen tubing dated.
Clinical record review for Resident 70 revealed a medical history that included Chronic Obstructive Pulmonary Disease and Other Sleep Apnea.
Current physician orders for Resident 70 instructed staff to apply oxygen via nasal cannula (a type of supplemental oxygen delivery device that is placed in the nostrils) at 4 liters per minute (LPM), change the oxygen tubing and canister weekly, and BiPAP to be applied at every bedtime, naps, and removed in the morning.
Clinical record review for Resident 70 revealed a current care plan that noted the resident has a risk for respiratory impairment and decreased cardiac output related to the medical history. Interventions noted in the care plan included using BiPAP and oxygen per physician orders.
Observation of Resident 70 on April 19, 2023, at 10:40 AM revealed the resident was sitting at the bedside in a wheelchair. The BiPAP mask was on a cluttered dresser top at the bedside and not protected from contamination. There was a nebulizer mask that was not protected from contamination and the tubing was not dated. The humidification bottle on the resident's oxygen compressor (a medical device that concentrates oxygen from the ambient air) was empty and not dated. An undated gallon of distilled water was found under a chair next to the bed. The water had been opened and not dated.
An interview at Resident 70's bedside with Employee 6 on April 19, 2023, at 11:38 AM confirmed the findings and revealed the BiPAP mask should be in a bag, and the oxygen tubing and the water should be dated. Employee 6 was unsure if the resident was supposed to have humidified oxygen. An additional observation revealed another nebulizer mask on a chair located next to the resident's bed. The nebulizer mask was on top of a wheelchair footrest placed on the chair. The nebulizer mask was not secured from any contamination and the tubing was not dated. Employee 6 proceeded to place the masks in a clear, plastic bag located on the dresser.
The above findings were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 19, 2023, at 2:30 PM.
28 Pa. Code 211.10(a) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed a...
Read full inspector narrative →
Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to ensure that the resident's attending physician addressed a pharmacy recommendation for one of five residents reviewed (Resident 30).
Findings include:
Review of the policy entitled Consultant Pharmacist Reports, reviewed March 17, 2023, indicates that the recommendations concerning medication therapy are communicated in a timely fashion. Recommendations are acted upon and documented by the facility staff and/or the prescriber within 30 days.
Review of Resident 30's clinical record revealed that the facility's pharmacist made recommendations to his physician on October 18, 2022, for the consideration of a gradual dose reduction (GDR) for the use of his Seroquel (an antipsychotic used to treat certain mood or mental disorders). The pharmacy recommendation document gives the prescriber three boxes to check, either agree, disagree, or other. The nurse practitioner signed the pharmacy recommendation on October 25, 2022, but did not check any of the boxes, and just noted stable. There was no documented evidence to indicate that Resident 30's nurse practitioner provided a rationale for refusing a GDR for the Seroquel.
An additional copy of Resident 30's pharmacy review dated October 18, 2022, was provided to this surveyor on April 21, 2023, at 9:00AM, which indicated a physician now noted that Resident 30 has a history of behaviors and medications are managed by tele psych. The additional information added to the pharmacy recommendation was not dated.
Interview with the Administrator on April 21, 2023, at 10:00 AM acknowledged the above findings for Residents 30 and indicated that there was no additional documented evidence in Resident 30's clinical record to indicate that tele psych addressed the pharmacy recommendation from October 18, 2022.
28 Pa. Code 211.2(a)(k) Physician services
28 Pa. Code 211.12(d)(3) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to ensure clinical justification for the addition of a schizophrenic diagnosis for one of five residents...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to ensure clinical justification for the addition of a schizophrenic diagnosis for one of five residents selected for medication regimen review (Resident 30).
Findings include:
Review of Resident 30's clinical record revealed that the facility admitted him on July 13, 2018, with a diagnosis of psychotic disorder and was followed by psychiatry since September 2018.
Review of Resident 30's medications revealed that he was ordered Seroquel (used to treat mental or mood disorders) 25 mg (milligrams) two times a day since August 17, 2020, to treat his psychotic disorder.
According to the Mayoclinic.org, schizophrenia is a serious mental disorder that includes symptoms such as hallucinations, delusions, disorganized thinking, and disorganized behavior. It further indicates that schizophrenia symptoms begin in the late 20's and that it is very rare for anyone over the age of 45 to get diagnosed with it for the first time.
A psychiatric evaluation performed by a nurse practitioner dated February 9, 2023, indicated that a diagnosis of paranoid schizophrenia was added to Resident 30's list of diagnosis. The nurse practitioner also increased Resident 30's Seroquel from 25 mg twice a day to 50 mg twice a day at this same time.
A psychiatric evaluation performed by a nurse practitioner dated March 29, 2023, indicated that Resident 30's paranoid schizophrenia is stable and being treated with Seroquel.
A Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated April 4, 2023, indicated that the facility added Resident 30's diagnosis of schizophrenia to the assessment.
There was no documented evidence in Resident 30's clinical record to indicate a justification for the addition of the schizophrenic diagnosis, nor were there documented behaviors in Resident 30's clinical record to justify the addition of this diagnosis.
Interview with the Administrator and Director of Nursing on April 20, 2023, at 2:10 PM acknowledged the above findings for Resident 30.
28 Pa. Code 211.9(a)(1)(k) Pharmacy services
28 Pa. Code 211.10(a) Resident care policies
28 Pa. Code 211.12(c)(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 select policies and procedures, observation, and staff interview, it was determined that the facility failed to secure medications on one of two nursing units (Wing 3).
Findings inc...
Read full inspector narrative →
Based on review of select policies and procedures, observation, and staff interview, it was determined that the facility failed to secure medications on one of two nursing units (Wing 3).
Findings include:
Review of the policy entitled Storage of Medications, last reviewed March 17, 2023, indicates that drugs and biologicals used in the facility are stored in locked compartments. Unlocked medication carts are not left unattended.
Observation on April 19, 2023, at 11:11 AM revealed an unlocked and unattended medication cart. The medications stored in the medication cart were available to other non-licensed staff, visitors, and residents. The medication cart continued to be unlocked and unattended until Employee 1, licensed practical nurse, returned from administering medications out of view at 11:17 AM. Interview with Employee 1 at this time confirmed that the medication cart was unlocked and out of view.
28 Pa. Code 211.9 (k) Pharmacy services
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to provide dental services for two of six residents reviewed ...
Read full inspector narrative →
Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to provide dental services for two of six residents reviewed (Residents 21 and 51).
Findings include:
Review of the policy entitled Dental Services, last reviewed March 17, 2023, revealed that routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care.
Review of Resident 21's clinical record revealed a dental exam dated March 23, 2023, that indicated she was being seen for an emergent exam due to having mouth pain for several weeks.
The dentist noted on March 23, 2023, that Resident 21 presented with an abscess surrounding one of her teeth. The dentist recommended an extraction. There was no documented evidence in Resident 21's clinical record to indicate the facility acted upon this recommendation. Resident 21's clearance for her extraction and placement on the next available dental visit was not completed until this surveyor brought up the dental concern.
Review of Resident 51's clinical record revealed a dental exam dated March 23. 2023. The dentist indicated that all Resident 51's remaining upper teeth would need extracted. There was no documented evidence in Resident 51's clinical record to indicate the facility acted upon this recommendation. Resident 51's clearance for his extraction and placement on the next available dental visit was not completed until this surveyor brought up the dental concern.
Interview with the Administrator on April 21, 2023, at 10:00 AM confirmed the above findings for Residents 21 and 51.
28 Pa. Code 211.15(a) Dental services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of facility documentation, clinical record review, observation, and staff interview, it was determined that the facility failed to implement measures to prevent or contain COVID-19 on ...
Read full inspector narrative →
Based on review of facility documentation, clinical record review, observation, and staff interview, it was determined that the facility failed to implement measures to prevent or contain COVID-19 on one of two nursing units (300 Unit, and Residents 35 and 36) and the main laundry unit of the facility.
Findings include:
Review of the Center of Medicare and Medicaid Services QSO (Quality, Safety and Oversight) memo revised on September 23, 2022, revealed that symptomatic residents regardless of their vaccination status, with signs or symptoms of COVID-19 (highly contagious respiratory illness) must be tested.
Review of the Center for Disease Control and Prevention website updated October 26, 2022, revealed that symptoms of COVID-19 may include but are not limited to fever, chills, cough, shortness of breath, fatigue, muscle aches, sore throat, congestion, headache, and nausea, vomiting, and diarrhea.
Record review for Resident 35 revealed a nursing progress note dated April 13, 2023, at 8:33 PM, which indicated that the resident was noted with cough and congestion. The resident's temperature was 99.3 degrees Fahrenheit, and the resident stated she was not feeling well.
Clinical record review for Resident 35 revealed a nursing progress note dated April 14, 2023, at 2:34 PM that the resident tested positive for COVID-19. The clinical nurse practitioner was notified, and the staff are awaiting new orders.
During an interview with the Director of Nursing on April 20, 2023, at 12:03 PM it was confirmed that Resident 35 was not tested when she initially showed symptoms of COVID-19. The Director of Nursing indicated that she read about the resident in morning report and educated the nurse about testing the resident when showing signs of COVID-19.
Clinical record review for Resident 36 revealed a nursing progress note dated April 11, 2023, at 10:54 AM that the resident complained of a sore throat and a rapid test for COVID-19 was positive and precautions were implemented per protocol.
Observation on April 20, 2023, at 11:34 AM of the room where Residents 35 and 36 resided revealed a plastic zippered clear barrier on entrance to the room and a sign outside door indicating the residents are on TBP (Transmission Based Precautions, special precautions to protect the spread of infection) and that those entering must wear PPE (Personal Protective Equipment, a N95 mask, eye protection/face shield, gown, and gloves to protect the wearer against excretions potentially contaminated with COVID-19).
Concurrent observation revealed that Employee 7, nurse aide, entered the room while wearing an N95 mask only and no other PPE. Employee 7 placed the lunch tray for Resident 35 on the overbed tray and took off the dome lid covering the food and placed it on the resident's bed. Employee 7 prepared the resident's meal in front of the resident who was in bed. Employee 7 left the resident room through the zippered barrier carrying the dome lid towards the meal cart and did not use hand sanitizer. Immediately, the surveyor interviewed Employee 7 and questioned as to why he did not wear a gown, eye protection, and gloves, and not sanitize his hands, and carried dome lid towards the meal cart. Employee 7 indicated that he didn't have to because he was going in and setting the food down. The surveyor pointed to the sign and plastic barrier and Employee 7 confirmed that appropriate PPE should have been worn and discarded before leaving the room. Employee 7 indicated that the dome lid should have been bagged in a plastic bag. Employee 7 also indicated he did not have a new N95 mask to change into and had to go to another room to get one.
During an interview with the Nursing Home Administrator and Director of Nursing on April 20, 2023, at 2:15 PM the surveyor informed them that Employee 7 failed to follow COVID-19 guidelines regarding PPE in a room shared by two residents who had COVID-19.
Observation of the main laundry unit on April 20, 2023, at 10:00 AM revealed a large, unbagged pile of clothing directly on the floor in the dirty area of the laundry. This pile of clothing contained various clothing items. A concurrent interview with Employees 12 and 13, laundry personnel, indicated that the pile of laundry was to be washed next.
The above observation in the main laundry unit was reviewed with the Nursing Home Administrator and Director of Nursing on April 20, 2023, at 2:00 PM. The Nursing Home Administrator further revealed that a barrier should have been placed between the floor and the laundry.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility to their call bells...
Read full inspector narrative →
Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility to their call bells for three of 24 residents reviewed (Residents 10, 38, and 52)
Findings include:
Clinical record review for Resident 10 revealed a diagnoses list that included a history of falling.
Resident 10's current care plan noted the resident was at risk for falls due to the resident's medical history. Interventions listed in the care plan included having the call bell in reach and having the call bell and commonly used articles within easy reach.
Observation of Resident 10 on April 18, 2023, at 1:00 PM revealed the resident was seated in a wheelchair at the foot of the bed with a fall mat on the floor and a bedside table between the wheelchair and the bed. The call bell was not readily accessible by the resident and not easily visible by the surveyor.
An interview with Employee 2, nurse aide, on April 18, 2023, at 1:15 PM regarding if Resident 10 should have the call bell revealed, Yes, every resident should. Employee 2 proceeded to find the call bell located at the head of the bed covered with the resident's blanket. Employee 2 placed the call bell on top of the blankets at the head of the bed still out of direct reach of the resident who was located at least six feet away. Employee 2 then left the room.
The above findings regarding Resident 10's call bell were reviewed with Employee 3, licensed practical nurse, on April 18, 2023, at 1:22 PM who then proceeded to untangle the call bell cord from another cord and placed the call bell within immediate reach of the resident.
Further observation of Resident 10 on April 20, 2023, at 1:35 PM revealed the resident was in bed. The call bell was hung over the back of a chair located three feet from the resident's bed.
The above finding regarding Resident 10's call bell was reviewed with Employee 4, licensed practical nurse, on April 20, 203, at 1:36 PM who proceeded to place the call bell within reach of the resident.
The additional observation for Resident 10 was reviewed with the Nursing Home Administrator and Director of Nursing on April 20, 2023, at 2:15 PM.
Clinical record review for Resident 38 revealed a current care plan that noted the resident is at risk for falls related to the medical history, which included vision impairment. Interventions listed in the care plan included to reinforce the need to call for assistance, have the call bell in reach, and have the call bell and commonly used articles within easy reach.
An interview with Resident 38 on April 19, 2023, at 11:58 AM revealed a history of vision problems. Concurrent observation revealed the resident was sitting near the foot of the bed in a wheelchair. The call bell was draped across the bed, located behind the resident and out of her direct reach, three feet away.
Clinical record review for Resident 52 revealed a current care plan that noted the resident is at risk for falls due to a history of falls, noncompliance with use of the call bell, and additional concerns related to the medical history. An intervention listed in the care plan included having the call bell in reach.
Observation of Resident 52 on April 19, 2023, at 10:49 AM revealed the resident was in bed. There was no observed call bell within reach.
Observation of Resident 52 on April 19, 2023, at 11:29 AM revealed the resident was still in bed with no call bell noted within reach of the resident. A concurrent interview with Employee 5, nurse aide, confirmed the resident did not have her call bell within reach. The call bell was located on the floor behind the resident's bed. Employee 5 proceeded to place the call bell within Resident 52's reach.
The above findings for Residents 10, 38, and 52 were reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 19, 2023, at 2:30 PM.
28 Pa. Code 211.12(d)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observations and staff and resident interview, it was determined that the facility failed to provide a clean, comfortable environment on two of two nursing units (200 Nursing Unit and 300 Nur...
Read full inspector narrative →
Based on observations and staff and resident interview, it was determined that the facility failed to provide a clean, comfortable environment on two of two nursing units (200 Nursing Unit and 300 Nursing Unit; Residents 2, 10, 37, 52, 16, 62).
Findings include:
Observation of Resident 52's fall mat on April 19, 2023, at 10:49 AM revealed a damaged and frayed perimeter. The corners were frayed with the underlying foam visible.
Observation of Resident 37's room on April 19, 2023, at 11:28 AM revealed the bathroom door was partially off the sliding rail and hanging in the door frame. Any movement of the door caused the whole door to swing precariously in the frame.
An interview with Employee 6, licensed practical nurse, on April 19, 2023, at 11:44 AM revealed it was unknown exactly how long the door had been like this. A concurrent observation also revealed a six to eight inch piece of cove base at the entrance to Resident 37's bathroom that was not secured and easily peeled back and revealed a marred subwall.
Observation of Resident 10's room on April 19, 2023, at 1:56 PM revealed marring to a corner of the wall just above the floor at the front of the room.
The above information for Residents 10, 37, and 52, was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 19, 2023, at 2:30 PM.
Observation of the resident lounge near the 200 Nursing Unit main nurse's station on April 19, 2023, at 11:52 AM and April 20, 2023, at 1:40 PM revealed a substantial accumulation of crumbs and debris located behind a dark colored recliner and wheelchair weigh station.
Observation of Resident 16's room on April 20, 2023, at 1:24 PM revealed two damaged floor tiles under the cooling / heating unit located under the window.
The above information regarding the lounge and Resident 16's room was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 20, 2023, at 2:15 PM.
Observations of Resident 2's room on April 19, 2023, at 12:30 PM revealed dried paint chips scattered on the floor and a build-up of dust/debris along the floor edges behind the bed and oxygen concentrator.
The above information regarding dried paint chips in Resident 2's room was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on April 19, 2023, at 2:15 PM.
Observation of Resident 2's room on April 20, 2023, at 12:30 PM revealed the same floor build-up behind the bed and oxygen concentrator.
The above information regarding the floor edges of Resident 2's room was again reviewed in a meeting with the Nursing Home Administrator on April 20, 2023, at 2:15 PM.
Observation on April 21, 2023, at 10:04 AM of the privacy curtain around Resident 62's bed revealed several brown and red stains. The above information regarding Resident 62's privacy curtain was reviewed in a meeting with the Nursing Home Administrator immediately after the observation.
28 Pa. Code 201.18 (b) (1) (3) Management
28 Pa. Code 207.2 (a) Administrator's responsibility
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
Based on clinical record review and staff interview, it was determined that the facility failed to notify the representative of the Office of the State Long-Term Care Ombudsman about resident transfer...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to notify the representative of the Office of the State Long-Term Care Ombudsman about resident transfers, for four of four residents reviewed for hospitalizations (Residents 16, 25, 37, and 52).
Findings include:
Clinical record review for Resident 16 dated February 4, 2023, at 10:03 PM revealed nursing documentation that the resident was sent to the hospital by ambulance for hypoglycemia (low blood sugar).
Nursing documentation for Resident 16 dated February 5, 2023, at 3:41 AM revealed the resident was admitted to the hospital for Encephalopathy (disease impacting the brain).
Clinical record review for Resident 25 revealed nursing documentation dated December 31, 2022, at 6:04 PM that revealed the resident was nonresponsive at 5:10 PM . The resident's blood sugar was 42 and a glucagon injection (medication used to increase the blood sugar) was ordered by the physician. The resident was later transferred to the hospital.
Nursing documentation for Resident 25 dated December 31, 2022, at 6:04 PM revealed the resident was admitted to the hospital for septic shock (a condition caused by infection).
Clinical record review for Resident 37 revealed nursing documentation dated January 1, 2023, at 4:49 PM that noted the resident's blood sugar was reading HI (this indicates the blood sugar reading was higher than the range limit of the glucometer, which measure blood sugar), was diaphoretic (sweating), not answering questions but shaking head, and then became unresponsive. The resident was transferred to the hospital.
Nursing documentation for Resident 37 dated January 1, 2023, at 11:01 PM revealed the resident was admitted to the hospital for sepsis (an infection of the bloodstream).
Clinical record review for Resident 52 dated February 12, 2023, at 8:00 PM revealed nursing documentation that indicated the resident was found diaphoretic and not moving the left arm. The resident was transferred to the hospital.
Nursing documentation for Resident 52 dated February 13, 2023, at 12:39 AM revealed the resident was admitted to the hospital for sepsis and PE (pulmonary embolism, which is a blood clot in the lungs).
Further clinical record review for the above residents revealed no evidence that the Office of the State Long-Term Care Ombudsman was notified as required about the transfers to the hospital.
An interview with the Nursing Home Administrator on April 20, 2023, at 1:30 PM confirmed that the Office of the State Long-Term Care Ombudsman was not notified about the transfers for the above residents. Furthermore, it was unknown when the facility last reported any resident transfers to the Office of the State Long-Term Care Ombudsman as required.
28 Pa. Code 201.14(a) Responsibility of license
28 Pa. Code 201.29(a) Resident rights
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "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.
- • 44% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
- • 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Brookline Nursing And Rehab's CMS Rating?
CMS assigns BROOKLINE NURSING AND REHAB an overall rating of 3 out of 5 stars, which is considered average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Brookline Nursing And Rehab Staffed?
CMS rates BROOKLINE NURSING AND REHAB's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 44%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Brookline Nursing And Rehab?
State health inspectors documented 31 deficiencies at BROOKLINE NURSING AND REHAB during 2023 to 2025. These included: 29 with potential for harm and 2 minor or isolated issues.
Who Owns and Operates Brookline Nursing And Rehab?
BROOKLINE 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 operates independently rather than as part of a larger chain. With 85 certified beds and approximately 79 residents (about 93% occupancy), it is a smaller facility located in MIFFLINTOWN, Pennsylvania.
How Does Brookline Nursing And Rehab Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, BROOKLINE NURSING AND REHAB's overall rating (3 stars) matches the state average, staff turnover (44%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Brookline 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 Brookline Nursing And Rehab Safe?
Based on CMS inspection data, BROOKLINE 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 3-star overall rating and ranks #1 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 Brookline Nursing And Rehab Stick Around?
BROOKLINE NURSING AND REHAB has a staff turnover rate of 44%, 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 Brookline Nursing And Rehab Ever Fined?
BROOKLINE 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 Brookline Nursing And Rehab on Any Federal Watch List?
BROOKLINE 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.