MILTON REHABILITATION AND NURSING CENTER
For profit - Corporation
138 Beds
BEDROCK CARE
Data: November 2025
Trust Grade
48/100
#462 of 653 in PA
Photo by Kevin Cooley
Photo by Kevin Cooley
Photo by Kevin Cooley
1 / 5 photos
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Milton Rehabilitation and Nursing Center has a Trust Grade of D, indicating below-average quality with some concerns. It ranks #462 out of 653 facilities in Pennsylvania, placing it in the bottom half of the state, but it is #3 out of 7 in Northumberland County, meaning there are only two local options that are better. The facility's trend is improving, having reduced its issues from nine in 2024 to just one in 2025. Staffing is average with a 3/5 rating and a turnover rate of 44%, which is slightly lower than the Pennsylvania average, but it has less RN coverage than 92% of state facilities, which is concerning as registered nurses can catch issues that other staff may miss. Specific incidents raised by inspectors include unsanitary conditions in the kitchen, failure to monitor the weights of residents properly, and inadequate dental care for residents, highlighting both the facility's strengths in terms of staffing and improvement trends, as well as significant weaknesses related to health and safety practices.
- Trust Score
- D
- In Pennsylvania
- #462/653
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 44% turnover. Near Pennsylvania's 48% average. Typical for the industry.
- Penalties ✓ Good
- $9,750 in fines. Lower than most Pennsylvania facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 23 minutes of Registered Nurse (RN) attention daily — below average for Pennsylvania. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Bottom 30%
No red flags
9 → 1 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 1 issues
The Good
-
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 fire safety.
The Bad
2-Star Overall Rating
Below Pennsylvania average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 44%
Near Pennsylvania avg (46%)
Typical for the industry
Federal Fines: $9,750
Below median ($33,413)
Minor penalties assessed
Chain: BEDROCK CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 41 deficiencies on record
Mar 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
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 of a call bell for ...
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 of a call bell for three of six residents reviewed (Resident 1, 2, and 3).
Findings include
Clinical record review for Resident 1 revealed a diagnosis list that included the following: dementia (general term to describe a group of symptoms related to loss of memory, judgment, language, complex motor skills, and other intellectual function, caused by the permanent damage or death of the brain's nerve cells), difficulty in walking, generalized muscle weakness, unsteadiness on feet, need for assistance for personal care, muscle wasting and atrophy (decrease in size or wasting away), abnormal posture, and a cataract (a cloudy area in the lens of the eye that may impact vision).
Review of the current care plan for Resident 1 revealed an activities of daily living (ADL) self-care performance deficit related to decreased physical ability, generalized weakness, blindness, and unsteadiness on feet. An intervention included, Encourage the resident to use bell to call for assistance.
Further review of Resident 1's care plan revealed the resident has a potential for falls due to impaired vision, blindness, unsteadiness on feet with generalized weakness, and medication history. An intervention included to, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed.
Observation on the [NAME] Nursing Unit on March 28, 2025, at 11:24 AM revealed a resident could be heard yelling loudly from one of the resident rooms. The resident was heard repeatedly yelling for a urine collection device and was also heard yelling, Or you're gonna have a mess again. The resident could be heard yelling by the surveyor from two rooms away and around a corner.
Further observation revealed the resident yelling was Resident 1 who was in his room on March 28, 2025, at 11:29 AM. The resident was sitting in a wheelchair near the foot of the bed and facing the unmade bed. There was a bedside table between the resident and the bed, and the resident was eating a snack at the bedside table. The resident's roommate was also present. Observation revealed the resident's call bell was at the head of the bed, which was at least six feet from the resident.
Upon the surveyor entering the room and attempting to question Resident 1, an unidentified staff member arrived and assisted the resident.
Further observation of Resident 1 on March 28, 2025, at 12:41 PM revealed the resident was sitting in a wheelchair at the foot of the bed and facing the bed. There was a bedside table between the resident and the bed, and staff were passing out lunch food trays. The resident's bed was now made, and the call bell was at the head of the bed and now covered up by blankets.
Clinical record review for Resident 2 revealed a diagnosis list that included the following: muscle wasting and atrophy, difficulty in walking, unsteadiness on feet, and unspecified lack of coordination.
Review of the current care plan for Resident 2 revealed an ADL self-care performance deficit related to generalized weakness. An intervention included, Encourage the resident to use bell to call for assistance.
Further review of Resident 2's care plan revealed the resident has a potential for falls due to a history of falls, impaired mobility secondary to generalized weakness, ambulatory dysfunction (difficulty with walking), and medication history. An intervention included, Place call light and frequently used objects within reach and encourage calling for assistance if needed.
Observation of Resident 2 on March 28, 2025, at 11:40 AM revealed they were lying in bed. The resident's call bell was not visible by the surveyor. A concurrent interview with Resident 2 questioning the location of the resident's call bell revealed the resident attempted to search on top and under the blankets and reach towards the side of the bed. The resident was unable to locate the call bell.
Further observation of Resident 2's bed revealed the call bell was clipped to the outer perimeter of the mattress, near the top of the bed, on the resident's right side of the bed. The activator was hanging away from the bed. Further observation revealed the resident was still unable to access the call bell.
Clinical record review for Resident 3 revealed a diagnosis list that included the following: dementia, repeated falls, muscle weakness, cataract, and abnormal posture.
Review of the care plan for Resident 3 revealed an ADL self-care performance deficit related to inability to care for self, secondary to the dementia process, generalized weakness, and unsteadiness on feet. An intervention included, Encourage the resident to use bell to call for assistance.
Further review of Resident 3's care plan revealed the resident has a potential for falls and has had actual falls due to unsteady gait and ambulating independently secondary to impaired cognition with poor safety awareness due to the dementia process. An intervention included, Place call light and frequently used objects within reach and encourage calling for assistance if needed.
Observation of Resident 3 on March 28, 2025, at 11:54 AM revealed the resident was sitting in a wheelchair at the foot of the bed. An attempted interview with the resident revealed the resident did not respond to the surveyor.
Observation of Resident 3's room revealed the call bell was not visible. Further observation revealed the call bell was found underneath a large stuffed animal at the head of the bed, inaccessible to Resident 3.
The findings for Residents 1, 2, and 3 were reviewed in a meeting with the Nursing Home Administrator (NHA) on March 28, 2025, at 12:30 PM. The NHA further noted that Resident 3 is independent and probably placed the stuffed animal on the call bell because the resident is particular with the way things are placed in the room. However, there was no intervention in the care plan that instructed staff on the preferred placement of Resident 3's call bell.
The facility failed to accommodate resident needs regarding the accessibility of call bells.
28 Pa. Code 211.12(d)(1)(5) Nursing services
Nov 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and resident and staff interview, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 2...
Read full inspector narrative →
Based on observation and resident and staff interview, it was determined that the facility failed to ensure that care and services were provided in a manner that enhanced resident dignity for one of 24 residents sampled (Resident 57).
Findings include:
Observation on November 3, 2024, at 10:19 AM revealed Resident 57 was wheeling himself down the hallway with his uncovered catheter bag hanging full of urine under his wheelchair.
Observation on November 3, 2024, at 11:52 AM revealed Resident 57 was participating in an activity in the activity room with his uncovered catheter bag hanging full of urine under his wheelchair.
Observation on November 3, 2024, at 2:03 PM revealed Resident 57 was in the hallway outside of his room with his uncovered catheter bag full of urine under his wheelchair.
Interview with Resident 57 on November 5, 2024, at 10:54 AM confirmed the facility placed the catheter bag covering on November 4, 2024, after the surveyor's discussion with Resident 57.
The surveyor reviewed the above findings during a meeting with the Director of Nursing on November 5, 2024, at 2:35 PM.
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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observations and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on one of two nursing units (West Side Nursing Unit).
Findi...
Read full inspector narrative →
Based on observations and staff interview, it was determined that the facility failed to provide a clean, comfortable, homelike environment on one of two nursing units (West Side Nursing Unit).
Findings include:
Observation on November 6, 2024, at 9:00 AM of the [NAME] Side Nursing Unit revealed the following:
A white air unit on the ceiling in the resident hallway adjacent to the nurse's station had a significant build-up of a black-colored substance on the interior vents.
Observation on November 6, 2024, at 9:15 AM of the [NAME] Side Nursing Unit shower room revealed the following:
A resident lift in the shower room had a significant accumulation of debris on the standing pad of the unit. The canvas storage bag attached to the lift had an extensive build-up of debris in the bag that included the following: two large pill-like objects that were partially dissolved, an open and unrolled elastic bandage, an exam glove, a crushed plastic disposable cup, and various other unidentified dirt and debris in the bottom of the canvas bag.
The resident shower stall contained black colored dot-like stains on the perimeter wall of the shower cove base where the wall met the floor.
There were multiple dead winged insects on the exterior of the light in the shower stall.
The shower curtain contained multiple black colored stains of various sizes on the interior/exterior of the shower curtain especially near the bottom of it.
Employee 1, nurse aide, was advised of the findings for the [NAME] Side Nursing Unit shower room on November 6, 2024, at 9:20 AM and proceeded to start cleaning out the canvas storage bag.
The above information was reviewed with the Director of Nursing on November 6, 2024, at 10:35 AM.
28 Pa. Code 201.18(b)(3)(e)(2.1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately...
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 ensure assessments accurately reflected residents' status for four of 24 residents reviewed (Residents 63, 84, 113, and 115).
Findings include:
Clinical record review for Resident 84 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated August 26, 2024, in which facility staff assessed the resident as receiving insulin during the last seven days in the assessment period.
Further clinical record review revealed no evidence that Resident 84 received insulin during the assessment period for the MDS noted above.
An interview with Employee 4, registered nurse assessment coordinator, on November 5, 2024, at 9:44 AM confirmed that Resident 84 did not receive insulin as indicated during the assessment period.
Clinical record review for Resident 63 revealed that on July 9, 2024, at 12:30 PM facility staff identified that they had right mandible (jaw) swelling, with Resident 63 indicating a bad tooth concern. Staff visualized a molar with a large filling that broken away from the filling and notified their physician.
Facility staff completed Resident 63's annual MDS on August 4, 2024, which indicated that the resident did not have any obvious or likely cavity or broken natural teeth.
Closed clinical record review for Resident 115 revealed that the facility completed a discharge MDS on August 12, 2024, which indicated that the resident was discharged to an acute care hospital.
Review of Resident 115's clinical record revealed social service documentation dated August 12, 2024, at 2:36 PM that they discharged to home with family.
The surveyor reviewed the above findings during an interview with the Director of Nursing on November 5, 2024, at 2:33 PM and November 6, 2024, at 10:41 AM.
Clinical record review for Resident 113 revealed a significant change MDS dated [DATE], in which facility staff assessed Resident 113 as receiving insulin during the assessment period.
Further clinical record review revealed no evidence that Resident 113 received insulin during the assessment period for the MDS noted above.
Interview with Employee 4 on November 5, 2024, at 9:46 AM confirmed Resident 113 did not receive insulin as indicted during the assessment period.
483.20(g) Accuracy of Assessments
Previously cited 12/15/23
28 Pa. Code 211.12(d)(1)(3)(5) Nursing 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 bathing support for a resident requiring staff assistance for one of two residen...
Read full inspector narrative →
Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide bathing support for a resident requiring staff assistance for one of two residents sampled for activities of daily living (Resident 57).
Findings include:
Interview with Resident 57 on November 3, 2024, at 11:50 AM revealed that the facility admitted him on August 29, 2024. Resident 57 stated that he did not get a shower for his first month in the facility.
Clinical record review for Resident 57 revealed his admission MDS (Minimum Data Set, an assessment completed at specific interval to determine care needs) dated September 5, 2024, noted staff assessed him as requiring partial/moderate assistance (helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for bathing.
Further review of Resident 57's clinical record revealed diagnoses including spina bifida and paraplegia.
Clinical record for Resident 57 revealed his preference for bathing is to receive a shower on Mondays and Thursdays. Review of Task documentation (electronic system of nurse aide documentation of activities of daily living care) revealed Resident 57 did not receive a shower from August 29 to October 6, 2024. There were no documented refusals.
The facility failed to provide assistance for bathing for a Resident 57 dependent on staff assistance.
These findings were reviewed during a meeting with the Director of Nursing on November 5, 2024, at 2:39 PM and she confirmed there was no further documentation that Resident 57 received showers per his preference.
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide cul...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of two residents reviewed for mood/behavior (Resident 25).
Findings include:
Clinical record review revealed the facility admitted Resident 25 on August 24, 2024, with a diagnosis of chronic Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event).
A review of Resident 25's plan of care revealed a care plan was added addressing Resident 25's history of trauma until September 24, 2024, one month after the resident's admission, and only indicated the resident had the potential for ineffective coping related to stress from a traumatic event of complications during childbirth.
Further review of Resident 25's clinical record contained no evidence the facility collaborated with the resident, and as appropriate, the resident's family, friends, and any other healthcare professionals (such as psychologists and mental health professionals) to identify triggers to develop and implement individualized interventions to prevent re-traumatization.
The Director of Nursing was made aware on November 4, 2024, at 2:00 PM that Resident 25's plan of care failed to indicate potential triggers for Resident 25's trauma and how staff can prevent re-occurrence.
A social service note dated November 5, 2024, at 4:05 PM revealed the social worker had met with Resident 25 to review triggers of the resident's trauma, which included seeing and speaking about very small children or babies had the ability to create increased frustration and sadness.
Resident 25's plan of care was revised on November 4th and 5th, 2024, with events that trigger the resident's trauma and individualized interventions to prevent re-occurrence of the trauma, after it was brought to the facility staff's attention.
483.25(m) Trauma informed care
Previously cited 12/15/24
28 Pa Code 211.12 (d)(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 observation and staff interview, it was determined that the facility failed to properly secure and account for resident medications and biologicals on one of two nursing units (West Side Nurs...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to properly secure and account for resident medications and biologicals on one of two nursing units (West Side Nursing Unit).
Findings include:
Observation on November 6, 2024, at 8:45 AM during the resident medication pass with Employee 2, licensed practical nurse, revealed a clear medication cup in the top drawer of the medication cart. The cup contained three pills: two round, brown-colored pills and a smaller pink colored one. The medication cup contained no labels, and it was unclear on the identity of the pills. A concurrent interview with Employee 2 revealed that it was unknown how long the cup of pills was in the cart because they were there when the employee started the shift.
Further observation of the medication cart revealed three unsecured pills in the bottom drawer of the cart. One pill was a half of a smaller round white colored pill, another was a pink colored oblong tablet, and the third was a round white colored pill. A concurrent interview with Employee 2 revealed it was unknown how long these pills were there or the identity of the pills.
Further observation of the medication cart revealed the front left, top corner of the cart was taped with multiple pieces of adhesive white colored tape. Parts of the tape were peeling away, and the peeling parts were discolored and contained small debris. An interview with Employee 2 revealed it was unknown how long the tape was on the cart or how the taped area was cleaned or sanitized.
The above information was reviewed with the Director of Nursing on November 6, 2024, at 10:35 AM.
28 Pa. Code 211.9(k) Pharmacy services
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
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 highest practicable care regarding physician ordered weights for three of n...
Read full inspector narrative →
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered weights for three of nine residents reviewed (Residents 22, 51, and 84) and appropriate positioning for meals for one of nine residents reviewed for nutritional concerns (Resident 105).
Findings include:
Clinical record review for Resident 84 revealed a diagnoses list that included severe protein-calorie malnutrition.
Review of the current care plan for Resident 84 revealed the resident has a potential nutrition problem for risk of malnutrition. The goal listed in the care plan for Resident 84 included maintaining adequate nutritional status as evidenced by maintaining weight, no signs/symptoms of malnutrition, consuming at least 60 percent of meals daily, and a target date listed as November 4, 2024.
Review of the most recent weights for Resident 84 were documented as:
September 7, 2024: 161 pounds (lbs)
October 7, 2024: 149.3 lbs (an 11.69 pound weight loss)
October 8, 2024: 153 lbs
A weight change note for Resident 84 on October 9, 2024, at 8:44 AM revealed a weight warning and a weight loss was noted. The recommendations from Employee 5, nutritional and dietetic technician, were a sugar free shake at lunch for nutritional support and place on weekly weights for four weeks for monitoring.
Facility documentation for Resident 84 titled, Physician's Call Report, and dated October 8, 2024, noted written communication to the physician of a 12-pound weight loss in one month. New orders placed on the sheet included: weekly weights for four weeks and a sugar free shake at lunch for nutritional support. The physician noted and signed the documentation on October 10, 2024.
Further review of Resident 84's clinical record revealed no evidence that the weights recommended by the dietary staff and ordered by the physician were completed.
An interview regarding the weights for Resident 84 on November 6, 2024, at 11:43 AM with Employee 5 revealed that the weights were not completed.
The above information for Resident 84 was reviewed with the Director of Nursing on November 6, 2024, at 12:07 PM.
Clinical record review for Resident 105 revealed a diagnoses list that included muscle weakness, dysphagia oropharyngeal and oral phase (difficulty swallowing), and muscle weakness.
Further clinical record review for Resident 105 revealed a quarterly Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated August 27, 2024, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 7, which indicated cognitive impairment. The MDS also revealed that staff assessed the resident's transfer status of chair/bed-to-chair (the resident's ability to transfer to and from a bed to a chair or wheelchair) as dependent.
Current physician orders for Resident 105 revealed the following orders: a diet order dated July 17, 2024, that instructed staff that the resident is to be OOB (out of bed) for all meals; an order dated July 2, 2024, that noted OOB (out of bed) for all meals every day and evening shift; and aspiration precautions (precautions taken to prevent food or fluids from entering the airway during eating) every shift for aspiration risk dated July 2, 2024.
Review of the current task list for Resident 105 revealed that the resident is Dependent x2 assist with hoyer lift. Another task noted the resident is to be OOB for all meals.
Review of the Treatment Administration Record (TAR) for Resident 105 for November 2024, revealed that staff were documenting the order for OOB for all meals with a check, which indicated it was completed. There were no documented refusals.
Review of the Speech Therapy documentation for Resident 105 titled, Speech Therapy Recommendations, dated July 5, 2024, and July 17, 2024, revealed a recommendation on both documents that the resident be OOB for all meals.
An interview with Employee 7, speech therapy, on November 5, 2024, at 12:58 PM revealed that the recommendations for Resident 105 to be out of bed during meals was to facilitate safe swallowing.
Observation of Resident 105 revealed the following:
November 4, 2024, at 12:25 PM: resident in bed eating lunch
November 5, 2024, at 9:01 AM: resident in bed eating breakfast
November 5, 2024, at 12:40 PM: resident in bed eating lunch
There was no further evidence documented for Resident 105 that indicated the resident refused to be out of bed for the meals or a reason noted why the speech therapy recommendations or physician order was not followed.
The above information for Resident 105 was reviewed with the Director of Nursing on November 5, 2024, at 2:18 PM.
Clinical record review for Resident 22 revealed a physician's order dated March 21, 2024, for staff to complete a daily weight every morning for CHF (congestive heart failure). Staff were to notify the physician if there was a weight increase or decrease by three-pounds in a day or an increase or decrease of five-pounds in a week. Weigh Resident 22 when he gets out of bed and attempt prior to breakfast.
Further review of Resident 22's clinical documentation revealed that there was no physician notification regarding their weight increase or decrease of three-pounds in a day or five-pounds in a week on the following dates:
April 5, 17, and 26, 2024
May 4 and 18, 2024
June 5, 12, 22, and 28, 2024
July 3, 5, 7, 17, 30, and 31, 2024
August 7, 2024
September 18, 22, and 28, 2024
October 9, 12, 23, and 26 2024
November 2, 2024
Clinical record review for Resident 51 revealed a physician's order dated July 3, 2024, for staff to complete a daily weight every morning for CHF. Staff were to notify the physician if there was a weight increase or decrease by three-pounds in a day or an increase or decrease of five-pounds in a week. Attempt to weigh Resident 51 prior to breakfast.
Further review of Resident 51's clinical documentation revealed that there was no physician notification regarding their weight increase or decrease of three-pounds in a day or five-pounds in a week on the following dates:
August 5, 2024
September 21, 25, and 26, 2024
October 2, 3, 7, 8, 14, 26, 27, and 28, 2024
The surveyor reviewed the above information during an interview on November 6, 2024, at 10:41 AM with the Director of Nursing.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected multiple residents
Based on clinical record review, and staff and resident interview, it was determined that the facility failed to provide dental services to meet the needs of residents for three of four residents revi...
Read full inspector narrative →
Based on clinical record review, and staff and resident interview, it was determined that the facility failed to provide dental services to meet the needs of residents for three of four residents reviewed (Residents 36, 46, and 63).
Findings include:
Clinical record review for Resident 63 revealed that the dentist saw them on June 14, 2023, and indicated that if Resident 63 experienced any intra-oral (inside mouth) pain or swelling, please refer to an oral surgeon for extractions as needed.
On July 9, 2024, at 12:30 PM facility staff identified that they had right mandible (jaw) swelling. Resident 63 indicated a bad tooth concern. Staff visualized a molar with a large filling that was broken away from the filling and notified their physician. Resident 63's physician ordered Clindamycin (an antibiotic) 450 milligrams by mouth (PO) three times a day (TID) for one week for an infected tooth.
Resident 63 saw the dentist again on July 18, 2024, who noted increased mouth pain and swelling. The dentist referred Resident 63 to an oral surgeon for x-rays and extraction of any teeth with less than favorable overall prognosis.
Resident 63 saw the dentist again on September 19, 2024, who noted that the resident had not yet seen by oral surgeon. The dentist rewrote the oral surgeon referral. After extractions, will evaluate further for any necessary restorative and removable prothesis.
Further review of Resident 63's clinical record revealed that the facility failed to refer the resident to an oral surgeon for follow-up as identified by the dentist on July 18, 2024, and September 19, 2024.
Clinical record review for Resident 46 revealed they saw the dentist on July 18, 2024. The dentist referred Resident 46 to the oral surgeon for x-rays and extractions of any teeth with less than favorable overall prognosis. Resident 46 saw the dentist again on September 19, 2024. The dentist indicated that the resident had not yet seen the oral surgeon and re-wrote the referral to the oral surgeon.
Further review of Resident 46's clinical record revealed that on October 26, 20244, at 7:22 PM they complained of a toothache. The facility notified the resident's provider. They saw Resident 46 on October 28, 2024, and ordered Orajel (for tooth pain).
There was no facility documentation that Resident 46 was referred to the oral surgeon after seeing the dentist on July 18, 2024, or September 19, 2024, or after her complaint of tooth pain on October 26, 2024.
The surveyor reviewed the above dental concerns during an interview with the Director of Nursing on November 6, 2024, at 10:41 AM.
In an interview with Resident 36, on November 3, 2024, the resident stated she has teeth that are broken off to the gum, and the dentist in the facility told her, They should all be pulled out and a plate put in there. The resident stated she would need an oral surgeon but doesn't know how to go about getting one.
A review of Resident 36's most recent dental visits revealed the resident was seen by the facility's dental service on May 22, 2024. The visit report indicated the resident was referred to an oral surgeon for extractions of all max teeth, tooth number 31, and any other teeth with a less than favorable prognosis. It was also suggested the resident use a high concentrate fluoride toothpaste such as Prevident 5000.
Resident 36 was again seen by the facility dentist on September 19, 2024, in which the visit report noted the resident has not yet been seen by an oral surgeon for full radiographic examination and extractions.
In an interview with Employee 6, transportation scheduler, on November 6, 2024, at 12:07 PM Employee 6 indicated Resident 36 required a medical facility oral surgeon due to having a pace maker and could not be seen in a non-medical facility based oral surgeons office and provided documentation of faxed referrals indicating attempts to schedule the resident have been unsuccessful on May 27, 2024, June 16, 2024, July 24, 2024, August 13, 2024, September, 23, 2024, and October 4, 2024. Employee 6 indicated there were no other medical facility oral surgeons to refer the resident to and the facility just finally got some other residents who were referred before Resident 36 in for an appointment. Although the facility was continuing to attempt to get the resident to the medical based oral surgeon, there was no evidence as of November 6, 2024, at 10:48 AM that the facility had implemented or addressed the suggested recommendation of the high concentrate fluoride toothpaste that was suggested back on May 22, 2024.
The above information regarding Resident 36, was reviewed with the Director of Nursing on November 6, 2024, at 10:48 AM.
483.55(b) Dental services
Previously cited 12/15/2023
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
28 Pa. Code 211.15. Dental services
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food borne...
Read full inspector narrative →
Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food borne illness in the facility's main kitchen.
Findings include:
Observation of the facility's main kitchen on November 3, 2024, at 8:52 AM revealed the following:
The right side of the food steamer was covered in dried food splatter.
The flooring under the steamer and the two-door cooler and stove area beside it contained a buildup of dirt, dried food, and debris.
Several potholders lying on tables and the meal service area were blackened and stained.
Dust and debris were observed on the shelves where food products were stored in the dry storage area.
A set of plastic risers was observed on the floor in the dry storage area with a carboard box of plastic lids and a box of food thickener sitting on it. The risers had a buildup of crumbs and debris in the crevices of the riser. A small fabric cooler lunch bag was observed inverted lying on top of the cardboard box of plastic lids with the lid hanging over the edge of the box, with liquid dripping from it, which had caused a large wet area on the plastic riser. Concurrent interview with Employee 3, cook, revealed the lunch bag is used for residents going out for dialysis and it had been washed and placed over the box to dry.
Peeling paint was in multiple areas of the dry storage area on the concrete block walls behind canned products.
A ceiling light cover in the dry storage room was broken/cracked.
Wire shelving units in the walk-in freezer contained dust build up.
A clear plastic wrapped pork loin was observed on the floor in the corner of the walk-in freezer under the shelving units.
Dust buildup was observed on condenser units in the front and back walk-in coolers.
A wooden shelf that extends from the steam table used for meal services was observed with corners and edges broken off exposing porous particle board material.
Dishwasher temperatures to ensure optimal sanitization revealed a completed log for October 2024. Although staff had not yet washed any items in the machine on November 3, 2024, when observed, there was no evidence of any monitoring for November 1, or 2, 2024. Employee 3 obtained a new blank form from an office in the department for November 2024, and indicated staff had not placed a new form for the change to November and confirmed there was no evidence the machine temperatures were checked on November 1, or 2, 2024, when washing resident tray items and food service items occurred.
The above information was reviewed with the Director of Nursing on November 4, 2024, at 2:05 PM.
483.60 (i)(2) Food store, distribute, maintain, sanitary
Previously cited 12/15/23
28 Pa. Code 201.14 (a) Responsibility of licensee
Dec 2023
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on review of employee personnel records, select facility policy review, and staff interview, it was determined that the facility failed to adequately implement its established abuse prohibition ...
Read full inspector narrative →
Based on review of employee personnel records, select facility policy review, and staff interview, it was determined that the facility failed to adequately implement its established abuse prohibition policy for two of five employees reviewed (Employees 7 and 8).
Findings include:
In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police background check within 30 days of hire on all prospective employees.
The policy entitled Abuse last reviewed October 13, 2023, indicates that a criminal background check will be conducted on all prospective employees. A significant finding on the background check will result in denied employment consistent with the criminal background check policy in accordance with State and Federal Regulation.
The policy entitled Pre-Employment Criminal Background Screening last reviewed on July 5, 2023, indicates that continued employment depends on successful completion of the criminal background check. If the results of the check are unfavorable, any offer of employment shall be withdrawn; or, if the employee has started working before the results of the check are available, employment may be terminated. The facility cannot employ anyone who has been found guilty by a court of law abusing, neglecting, or mistreating nursing facility residents.
Review of Employee 7's, receptionist, personnel record revealed that the facility hired her on August 2, 2023. There was no documented evidence in Employee 7's personnel file to indicate the facility obtained a criminal history background report until December 14, 2023, when the surveyor brought it to the attention of administration.
Review of Employee 8's, dietary aide, personnel record revealed that the facility hired him on October 4, 2023. There was no documented evidence in Employee 8's personnel file to indicate the facility obtained a criminal history background report until December 14, 2023, when the surveyor brought it to the attention of administration.
Interview with Employee 9, human resources director, on December 14, 2023, at 11:08 AM, confirmed the above findings.
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a)(c) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**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 ensure assessments accurately...
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 ensure assessments accurately reflected resident status for two of 23 residents reviewed (Residents 12 and 58).
Findings include:
Clinical record review for Resident 58 revealed the resident was admitted to the facility on [DATE].
An admission MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) for Resident 58 dated September 24, 2023, noted the facility staff assessed the resident as receiving an anticoagulant six days in the assessment period.
Further clinical record review revealed no evidence that Resident 58 received an anticoagulant during the assessment period for the MDS noted above.
An interview with Employee 11, the Registered Nurse Assessment Coordinator, on December 14, 2023, at 11:09 AM confirmed that Resident 58 did not receive an anticoagulant.
The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 2:57 PM.
Clinical record review for Resident 12 revealed that the facility completed an annual MDS assessment on November 27, 2023, which indicated that the resident was not on dialysis. Review of Resident 12's clinical record revealed a physician's order dated November 15, 2023, and a care plan dated August 4, 2022, for her to attend dialysis on Monday, Wednesday, and Friday.
The surveyor reviewed the above MDS discrepancy for Resident 12 during an interview with the Nursing Home Administrator and Director of Nursing on December 13, 2023, at 2:42 PM.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on review of select facility policy and procedures, clinical record review, and staff interview, it was determined that the facility failed to maintain an acceptable parameter of nutritional sta...
Read full inspector narrative →
Based on review of select facility policy and procedures, clinical record review, and staff interview, it was determined that the facility failed to maintain an acceptable parameter of nutritional status for one of six residents reviewed for nutrition concerns (Resident 58).
Findings include:
The policy entitled Weight Assessment and Intervention Policy, last reviewed without changes on October 13, 2023, revealed that, Any weight change of greater than or less than five pounds within 30 days will be retaken for confirmation. A significant weight change is defined as: more or less than five percent within 30 days, and more or less than 10 percent within six months. The policy further noted that if the weight loss meets the definition of significant then the dietitian should discuss with the interdisciplinary team and make recommendations. The policy noted the dietitian will also review the monthly weights by the 10th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the dietitian whether the definition of significant weight change is met.
Review of Resident 58's current care plan revealed the resident has a nutritional problem or potential nutritional problem and inadequate intake related to impaired vision. Some interventions included: monitor, record, and report to the physician as needed signs and symptoms of malnutrition: emaciation (cachexia - being abnormally thin or weak), muscle wasting, and significant weight loss of three pounds in one week, greater than five percent in one month, greater than 7.5 percent in three months, or greater than 10 percent in six months; weigh per physician orders and notify the physician, responsible party, and dietitian of any significant changes.
Clinical record review for Resident 58 revealed assessments of the weights as follows:
November 1, 2023, 174.6 pounds
November 8, 2023, 175.2 pounds
November 15, 2023, 175.0 pounds
December 1, 2023, 156.2 pounds
Resident 58 experienced an 18.4 pound significant weight loss of 10.5 percent in 30 days, from November 1, 2023, to December 1, 2023.
There was no evidence that Resident 58's 30-day weight loss from November 1, 2023, to December 1, 2023, was addressed by the registered dietitian or physician as of December 13, 2023, nor any evidence Resident 58's registered dietitian or physician was made aware of Resident 58's weight loss as of December 13, 2023. There was also no evidence that Resident 58 was reweighed to ensure accuracy of the weight obtained on December 1, 2023.
The above information was reviewed with the Nursing Home Administrator and Director of Nursing on December 13, 2023, at 2:30 PM.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain m...
Read full inspector narrative →
Based on review of facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered pain medications for one of three resident reviewed (Resident 83).
Findings include:
The facility policy entitled, Administering Pain Medications, last reviewed without changes on October 13, 2023, revealed that the facility will assess a resident's level of pain prior to administering non-narcotic or narcotic analgesics. Staff will follow the medication administration per the physician's order and utilize standardized pain assessment tools including the 10-point pain intensity scale. The facility policy did not identify what mild, moderate, and/or severe pain was per the 10-point pain intensity scale.
Review of Physiopedia's and Wikipedia's definition of the numeric pain rating scale (parameters) from zero to 10 indicated that no pain was identified as zero, mild pain was identified as one to three, moderate pain was identified as four to six, and severe pain was identified as seven to 10.
Clinical record review for Resident 83 revealed physician's orders for the following pain medications:
Ordered on August 16, 2023, Acetaminophen (for mild pain) 500 milligrams (mg) 1 tablet by mouth (PO) every 6 hours as needed (PRN) for pain.
Ordered on September 21, 2023, Morphine (for severe pain) 100 mg/5 ml (milliliters) 0.25 ml PO every 4 hours PRN for pain/shortness of breath.
There was no documentation that the facility identified which pain medication that staff were to administer for mild, moderate, and/or severe pain parameters or that the facility identified that multiple medications were available for the same pain parameter.
Review of Resident 83's September, October, November, and December 2023 MAR (medication administration record, a form to document medication administration) revealed that staff administered the following PRN pain medications:
Acetaminophen 500 mg 1 tablet PO every 6 hours PRN for pain
September 22, 2023, at 9:11 PM for a pain level of 6.
September 23, 2023, at 3:34 AM for a pain level of 4.
October 4, 2023, at 3:35 PM for a pain level of 7.
October 5, 2023, at 3:21 PM for a pain level of 7.
October 6, 2023, at 12:23 PM for a pain level of 5.
October 15, 2023, at 1:00 PM for a pain level of 7.
October 19, 2023, at 11:28 AM for a pain level of 5.
October 19, 2023, at 7:43 PM for a pain level of 7.
October 20, 2023, at 1:55 AM for a pain level of 5.
October 30, 2023, at 3:47 AM for a pain level of 5.
November 21, 2023, at 5:44 AM for a pain level of 5.
November 23, 2023, at 7:17 PM for a pain level of 7.
November 26, 2023, at 3:21 PM for a pain level of 7.
November 29, 2023, at 5:18 PM for a pain level of 7.
December 3, 2023, at 6:30 PM for a pain level of 4.
December 10, 2023, at 8:32 PM for a pain level of 6.
December 12, 2023, at 8:23 PM for a pain level of 5.
Morphine 100 mg/5 ml 0.25 ml PO every 4 hours PRN for pain/shortness of breath
November 5, 2023, at 10:28 AM for a pain level of 6.
November 8, 2023, at 11:30 AM for a pain level of 5.
December 7, 2023, at 6:43 PM for a pain level of 6.
December 8, 2023, at 7:35 PM for a pain level of N/A (not applicable).
The surveyor reviewed Resident 83's pain information during an interview with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 2:18 PM.
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 F0699
(Tag F0699)
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 and resident interview, it was determined that the facility failed to identify trigger...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of five residents reviewed for mood/behavior (Resident 18).
Findings include:
Clinical record review for Resident 18 revealed a diagnosis of Chronic Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event) since admission on [DATE].
During an interview with Resident 18 related to her diagnosis of PTSD on December 12, 2023, at 10:47 AM revealed that she did not want to discuss her triggers, she stated that she has talked to a professional about it.
A review of Resident 18's most recent quarterly minimum data set (MDS, an assessment completed by the facility at intervals to determine care needs) assessment, dated September 1, 2023, indicated PTSD was an active diagnosis for Resident 18.
Further review of Resident 18's current care plan revealed an identified behavioral-emotional problem indicating Resident 18 has a psychosocial well-being problem related to a diagnosis of PTSD and anxiety. There were no identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring).
Clinical record review of Resident 18's current care plan revealed an identified problem of trauma-informed care related to PTSD, with no identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it were reoccurring).
Resident 18 saw a nurse practitioner with psychological services six times in the last year with the PTSD diagnosis listed with no treatment plan or triggers noted.
Further review of Resident 18's clinical record revealed documentation by a licensed clinical social worker on October 19, 2023, noting that the diagnosis of PTSD is related to neglect, verbal, and emotional abuse by Resident 18's ex-husband/caretaker.
An interview with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 2:20 PM confirmed these findings.
The facility failed to identify and care plan triggers that may retraumatize Resident 18 related to her diagnosis of PTSD.
28 Pa Code 211.12 (a)(d)(3)(5) Nursing services
28 Pa Code 211.11(d) Resident care plan
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive l...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address dementia and cognitive loss displayed by one of one resident reviewed (Resident 52).
Findings include:
Clinical record review for Resident 52 revealed the facility admitted her on May 4, 2022, with a diagnosis including Dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life). A review of Resident 52's most recent annual Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated March 1, 2023, indicated that the facility assessed Resident 52 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 52'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.
The findings were reviewed with the Director of Nursing and Nursing Home Administrator during a meeting on December 13, 2023, at 2:15 PM. Further interview with the Director of Nursing on December 15, 2023, at 9:35 AM confirmed the facility had no further documentation that the facility developed and implemented an individualized person-centered care plan to address Resident 52's dementia and cognitive loss.
28 Pa Code 211.12 (d)(1)(3)(5) Nursing services
28 Pa Code 211.11(d) Resident care plan
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 and resident and staff interview, it was determined that the facility failed to assist a resident to obtain routine dental services for one of two residents reviewed fo...
Read full inspector narrative →
Based on clinical record review and resident and staff interview, it was determined that the facility failed to assist a resident to obtain routine dental services for one of two residents reviewed for dental concerns (Resident 18).
Findings include:
Interview with Resident 18 on December 12, 2023, at 12:46 PM revealed that she could not remember when she last saw the dentist.
Clinical record review for Resident 18 revealed that the facility admitted her on October 1, 2020, with payment sources that included the state Medicaid benefit.
Further review of Resident 18's clinical record revealed she last saw the dentist on March 2, 2023. A review of this progress note revealed that Resident 18 was scheduled for her next visit for prophylactic dental cleaning on July 27, 2023. Further review of the progress note revealed Resident 18's oral condition would benefit from Peridex (medication used to treat swelling, redness, and bleeding gums), and daily use of high-concentrate fluoride toothpaste, noting that the facility should consult Resident 18's physician regarding these recommendations.
There were no further dental visits, or documentation indicating the facility addressed the dentist's recommendations with Resident 18's physician.
An interview with the Nursing Home Administrator on December 15, 2023, at 9:12 AM confirmed that Resident 18 should have seen the dentist in July 2023 for cleaning.
An interview with the Director of Nursing on December 15, 2023, at 11:55 AM confirmed these findings and had no further information to indicate that Resident 18 received routine dental services every six months as the State plan allows. She stated there was no evidence that the facility followed up with Resident 18's physician regarding the dentist's recommendations.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
28 Pa. Code 211.15. Dental services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0840
(Tag F0840)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review and staff interview, it was determined that the facility failed to provide and arrange ap...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed clinical record review and staff interview, it was determined that the facility failed to provide and arrange appointments for outside services for one of 24 residents reviewed (Resident 115).
Findings include:
Review of Resident 115's closed clinical record revealed that the facility admitted her on October 19, 2023. A review of Resident 115's hospital Discharge summary dated [DATE], indicated that the hospital prescheduled Resident 115 for a follow up with her neurologist to be completed October 24, 2023, at 1:30 PM.
There was no documented evidence in Resident 115's closed clinical record to indicate that the facility acknowledged the follow up appointment for Resident 115's neurologist or planned arrangements for Resident 115 to attend the appointment. There was also no documented evidence to indicate the facility rescheduled or cancelled Resident 115's appointment with her neurologist.
Interview with the Administrator on December 14, 2023, at 10:05 AM confirmed the above findings for Resident 115.
28 Pa. Code: 201.21(c) Use of Outside Resources
28 Pa Code:201.18(b)(1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection regarding transmissio...
Read full inspector narrative →
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection regarding transmission-based precautions and linen containment on one of two nursing units (East Nursing Unit, Resident 110).
Findings include:
Nursing documentation for Resident 110 dated December 4, 2023, at 11:19 AM revealed the resident was on isolation precautions for Methicillin-resistant Staphylococcus aureus (MRSA; a bacteria that infects the body and is resistant to certain antibiotics).
Review of the current physician orders for Resident 110 revealed the resident was on contact precautions (transmission based precautions that requires additional personal protection equipment such as a gown and gloves to avoid direct or indirect contact with a resident and/or their environment to prevent the spread of infection) due to MRSA.
Observation of Resident 110's room on December 13, 2023, at 11:48 AM and again at 1:00 PM revealed a sign on the door that indicated the resident was on contact isolation. Inside the door was a smaller sized red isolation bin with a lid that had the contents (which appeared to be a blue disposable gown and multiple white ties hanging over the edge) protruding from under the lid and almost touching the floor. An interview with Employee 10, licensed practical nurse, on December 13, 2023, at 1:10 PM revealed that the nurse aides are responsible for emptying the bin.
Observation of the East Nursing Unit hallway on December 13, 2023, at 12:12 PM revealed an overflowing linen cart with the lid ajar due to protruding linens.
Observation of the shower/bathroom located next to the nutrition room on the East Nursing Unit on December 13, 2023, at 1:14 PM revealed an overflowing linen cart with the lid ajar due to protruding linens. It appeared to be the same cart as previously seen in the hallway and was still overflowing and not emptied.
The Nursing Home Administrator and Director of Nursing were notified of the above findings on December 13, 2023, at 3:00 PM and further noted that the linen carts are pushed into the shower rooms during lunch time.
Observation of Resident 110's room on December 14, 2023, at 12:26 PM again revealed a smaller sized red isolation bin with a lid that had the contents (which appeared to be a blue disposable gown and multiple white ties hanging over the edge) protruding from under the lid. A second red isolation bin inside the room, which held soiled linens and laundry items had a plastic cup that was partially filled with a white colored liquid and a plastic bowl sitting on top of the lid.
The above findings for Resident 110's room were reviewed with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 2:57 PM.
483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control
Previously cited 1/10/23
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident care policies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to ensure a resident received the pneumococcal immunization for one of five residents reviewed for immunization concerns (Resident 107).
Findings include:
Review of the policy entitled Influenza and Pneumococcal Immunizations, last reviewed without changes on October 13, 2023, revealed that the facility will provide pneumococcal immunizations to minimize the risk of residents acquiring, transmitting, or experiencing complications from pneumococcal disease.
Review of the immunizations for Resident 107 revealed no evidence of a pneumococcal immunization for the resident who was admitted to the facility on [DATE].
An interview with Employee 12, Infection Preventionist, on December 15, 2023, at 12:05 PM revealed that Resident 107 did not receive and was not offered a pneumococcal immunization by the facility.
Further review of Resident 107's clinical record revealed admission documents that noted facility documentation titled Pneumococcal (Pneumonia) Vaccine, that indicated the resident had received the vaccine prior to admission on [DATE]. The kind of vaccination was marked as unknown. The facility documentation indicated that Pneumococcal immunization status of all residents will be determined on admission regardless of date of admission. Vaccination will be offered to all residents who cannot provide documentation of previous vaccination. Those who are unsure of their vaccination status and consent to the vaccine will receive the vaccine. The form noted the resident consented to the vaccine and was signed and dated by the resident on October 16, 2023.
After surveyor questioning, Employee 12 produced further documentation titled Patient Summary for Resident 107 that indicated the resident had received the PNU-13 vaccine on January 26, 2016. Employee 12 was unsure if Resident 107 should receive additional vaccinations based on the findings and will have to check.
An interview with Employee 12 on December 15, 2023, at 2:16 PM revealed Employee 12 produced further documentation titled Pneumococcal Vaccine Timing for Adults Who Previously Received PCV13, and indicated the resident should have been offered the PPSV23 vaccine based on Centers for Disease Control and Prevention recommendations. Employee 12 confirmed that the vaccine was not offered or administered to the resident.
The facility failed to follow-up with the pneumococcal vaccinations for Resident 107 and ensure the resident received the appropriate vaccinations as recommended.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(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 interviews, it was determined that the facility failed to provide a clean, comfortable, home-like environment on two of two nursing units (East Nursing Unit and [NAME] ...
Read full inspector narrative →
Based on observations and staff interviews, it was determined that the facility failed to provide a clean, comfortable, home-like environment on two of two nursing units (East Nursing Unit and [NAME] Nursing Unit; Residents 4, 7, 25, 52, 99, and 110).
Findings include:
Observation of a storage room with various respiratory equipment and tube feedings with the title Coat Rack on the door located on the East Side Nursing Unit on December 13, 2023, at 12:54 PM revealed: a green lidded bowl on top of a water heater that held contents, which were covered in a white, fuzzy, mold-like substance, a large plastic fountain drink cup with a straw in the lid discarded under the rack that held tube feedings, a balled-up surgical mask on a shelf holding respiratory supplies, and half a 12-ounce can of soda on a shelf next to exam gloves. These findings were reviewed with Employee 10, a licensed practical nurse, on December 13, 2023, at 1:10 PM.
Observation of a shower/bathroom located next to the nutrition room on the East Nursing Unit on December 13, 2023, at 1:14 PM revealed the following: a strong offensive odor noted upon entering the room, black spots covering the caulk in the corners of a shower stall, a hole in the wall along the lower border of a temperature gauge located above the shower control handle, a handrail near the sink was loose and starting to detach from the wall, a piece of protective wall covering under the handrail was broken and jagged.
Observation of a shower/bathroom on the East Side Nursing Unit on December 14, 2023, at 1:27 PM revealed a wooden shelf located in a shower stall that had two Exelon transdermal patches stuck to the top of it and a large protective wall covering was starting to detach from the wall near the ceiling.
Observation of Resident 110's room on December 13, 2023, at 1:00 PM revealed an accumulation of debris (including a plastic spoon, paper debris, crumbs, and a baked goldfish snack) and grime on the floor. The resident's bed sheet was covered in crumbs and stained especially near the foot of the bed.
The above information for the East Side Nursing Unit shower and bathroom, storage closet, and Resident 110's room was reviewed with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 2:57 PM.
Observation of the East Nursing Unit on December 12, 2023, at 11:31 AM, December 13, 2023, at 10:23 AM, and December 14, 2023, at 2:51 PM revealed that Resident 4's room had a very strong urine smell.
The surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on December 14, 2023, at 3:00 PM.
Observation of the [NAME] Nursing Unit on December 12, 2023, at 10:34 AM revealed the following:
Resident 25's floor in her room was dirty with brown spillage spots, trash, and food on the floor.
Resident 99's floor was dirty between Bed A and the wall, there were multiple areas on the floor with dried food and spillage spots.
Residents 7 and 52's floor was extremely dirty, with multiple spillage spots, dried food, and trash on the floor.
28 Pa. Code 201.18(b)(3) Management
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for five of five residents reviewed (...
Read full inspector narrative →
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for five of five residents reviewed (Residents 6, 25, 29, 44, and 69).
Findings include:
According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip-lock bag.
Clinical record review for Resident 44 revealed a current physician's order for staff to administer Albuterol Sulfate nebulizer solution 0.083% one vial inhale orally via nebulizer every 6 hours as needed for wheezing or shortness of breath.
Observation of Resident 44's bedside stand on December 12, 2023, at 11:23 AM and December 13, 2023, at 10:22 AM revealed that there was a nebulizer machine with nebulizer tubing, cannister, and mouthpiece connected. The canister and mouthpiece were unbagged and lying directly on the resident's bedside stand.
The surveyor reviewed the above information during with the Director of Nursing and the Nursing Home Administrator on June 15, 2023, at 2:30 PM.
Clinical record review for Resident 25 revealed a physician's order dated July 4, 2023, for staff to administer Resident 25 oxygen at two liters per minute via the nasal cannula (medical tubing with two nasal prongs used to deliver supplemental oxygen into the nose) continuously.
Observation of Resident 25's Room on December 12, 2023, at 10:34 AM revealed Resident 25 was out of the room and her oxygen tubing was hanging on the overbed table unbagged, with the nasal cannula piece directly touching the floor.
The surveyor reviewed the above information for Resident 25 with the Director of Nursing and the Nursing Home Administrator in a meeting on December 14, 2023, at 2:18 PM.
Clinical record review for Resident 29 revealed a current physician's order dated November 17, 2023, that indicated the resident was to wear BiPAP (Bi-level positive airway pressure; a mask worn during sleep that helps to keep the airways open) every night with oxygen at two liters per minute.
Observation of Resident 29's BiPAP on December 13, 2023, at 9:43 AM and 12:48 PM and again on December 14, 2023, at 12:38 PM revealed the resident was awake and sitting upright in bed. The resident's BiPAP mask was draped over the resident's BiPAP machine located on a dresser next to the bed. The mask was not bagged or protected from contamination from the ambient environment during any of these observations.
Clinical record review for Resident 69 revealed a current physician's order dated September 5, 2023, that indicated the resident was to wear supplementary oxygen via nasal cannula continuously at four liters per minute.
Nursing documentation for Resident 69 dated December 9, 2023, at 11:43 PM revealed the resident was sent to the hospital. Further documentation dated December 10, 2023, at 9:00 AM revealed the resident was admitted to the hospital.
Observation of Resident 69's bedroom on December 13, 2023, at 9:45 AM and again on December 14, 2023, at 12:38 PM revealed a nebulizer mask on the bedside table. The mask was not bagged or protected from contamination from the ambient environment.
Clinical record review for Resident 6 revealed a current physician's order dated November 28, 2023, that indicated the resident was to receive ipratropium-albuterol inhalation solution (a combination of medication that helps to reduce inflammation in the airways and increase airflow to the lungs) 0.5 - 2.5 milligrams in 3 milliliters and inhale orally via nebulizer every six hours as needed for wheezing and shortness of breath.
Observation of Resident 6's room on December 14, 2023, at 12:30 PM revealed that there was a nebulizer mask hanging from the nebulizer machine on a dresser next to the bed. The mask was not bagged or protected from contamination from the ambient environment.
The above findings for Residents 6, 29, and 69 were again noted on December 14, 2023, at 1:45 PM during a walk through with the Nursing Home Administrator who reported the oxygen equipment should be bagged.
483.25(i) Respiratory/tracheostomy Care and Suctioning
Previously cited 1/10/23
28 Pa. Code 211.10 (c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on review of select facility policies, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (...
Read full inspector narrative →
Based on review of select facility policies, observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 17 and 52).
Findings include:
The facility's medication error rate was 15.15 percent based on 33 medication opportunities with two medication errors.
The facility policy entitled, Administering Medications, last reviewed without changes on October 13, 2023, revealed that medications must be administered in accordance with physician orders. The individual administering the medication must check the label to verify the right medication, right dosage, right time, and the right method of administration before giving the medication.
Observation of a medication administration pass on December 12, 2023, at 8:42 AM revealed Employee 1, licensed practical nurse, preparing to administer Spiriva (treats breathing disorders) one capsule to inhale orally, Fenofibrate (treats high cholesterol) 145 mg (milligrams), Raloxifene (treats osteoporosis) 60 mg, and Ditropan XL (treats overactive bladder) 5 mg to Resident 52. Employee 1 handed the Spiriva inhaler to Resident 52, and instructed her to take a deep breath in. Employee 1 took back the Spiriva inhaler after Resident 52 inhaled on the medication one time. Review of the manufacture's guidelines for Spiriva, revised November 2021, indicated that two inhalations are to be completed for the same capsule, to ensure that the full medication dose is delivered each day. Employee 1 did not provide further education or prompting to Resident 52 to complete a second inhalation of the Spiriva capsule.
Employee 1 crushed the Fenofibrate, Raloxifene, and Ditropan XL and mixed them with pudding prior to administering them to Resident 52. Review of the Fenofibrate and Ditropan medication cards (a blister pack of the medication sent by pharmacy) revealed a sticker indicating that the medications should not be crushed. Review of the facility pharmacy's do not crush list, copyrighted in 2020, indicates that Raloxifene should not be crushed.
Interview with Employee 1 on December 12, 2023, at 10:26 AM confirmed the above findings for Resident 52.
Interview with the Administrator and Director of Nursing on December 13, 2023, at 2:00 PM acknowledged the above findings regarding Resident 52's medication errors.
Observation of a medication administration pass on December 12, 2023, at 9:18 AM revealed that Employee 2, licensed practical nurse, administered Fluticasone Propionate 50 mcg (micrograms) per spray two sprays per nostril to Resident 17.
Clinical record review for Resident 17 revealed a current physician's order for Fluticasone Furoate 27.5 mcg per spray two sprays in both nostrils daily for allergies.
Interview with Employee 2 on December 12, 2023, at 10:09 AM confirmed that she administered Fluticasone Propionate 50 mcg per spray not Fluticasone Furoate 27.5 mcg per spray as ordered to Resident 17. Employee 2 acknowledged that she administered the incorrect medication and incorrect dosage of the medication to Resident 17.
The surveyor reviewed the above information during an interview on December 12, 2023, at 1:18 PM with the Director of Nursing and on December 13, 2023, at 2:41 PM with the Nursing Home Administrator.
28 Pa. Code 211.9 (a)(1)(k) Pharmacy services
28 Pa. Code 211.10(a)(c) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, it was determined that the facility failed to store food in a manner to prevent the potential spread of foodborne illness in the main kitchen and one of two n...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to store food in a manner to prevent the potential spread of foodborne illness in the main kitchen and one of two nursing units (East Nursing Unit).
Findings include:
Observation of the facility's kitchen on December 12, 2023, at 10:11 AM revealed Employees 3 and 4, dietary aides, were utilizing the dishwasher to clean breakfast dishes. Concurrent observation of the dishwasher gauges revealed that the wash temperature was 110 degrees Fahrenheit, and the final rinse temperature was 142 degrees Fahrenheit. There was no sanitizing agent connected to the dishwasher. Employee 5, dietary manager, acknowledged the low wash and rinse temperatures on the dishwasher and began cleaning out the three-tiered sink to hand wash dishes. She indicated that the concern was identified that morning and a contractor was onsite to fix the hot water boiler currently. Employees 3 and 4 did not identify the low water temperatures and that the facility's dishes were not being sanitized by high temperatures prior to being identified by the surveyor.
Review of the dishwasher's temperature log dated December 2023 revealed the standard dishwasher wash temperatures should be between 140 and 160 degrees Fahrenheit and the rinse temperatures should be between 180-194 degrees Fahrenheit. Staff were to notify the supervisor if not within standard. Review of the December 12, 2023, dishwasher temperatures for breakfast revealed that the wash temperature was 165 degrees Fahrenheit, and the rinse temperature was 150 degrees Fahrenheit. Interview with Employee 5 on December 12, 2023, at 10:44 AM revealed that she was not aware of these temperatures prior to staff washing dishes and acknowledged that staff should not have utilized the dishwasher that morning.
Interview with Employee 6, maintenance, on December 12, 2023, at 1:58 PM revealed that a concern was identified with the facility's boiler that supplies the kitchen on December 11, 2023, with a contractor fixing the concern. Employee 6 again noted issues when he arrived on-site December 12, 2023, at 6:00 AM and again notified the contractor, with them arriving at the facility shortly thereafter. Employee 6 revealed that the contractor had again fixed the concern and that the boiler was back online. He also noted that there was a hot water booster for the dishwasher to meet the hot water sanitizing requirements.
The facility's dishwasher temperatures did not meet temperatures to properly sanitize the facility's dishes.
This surveyor reviewed the above concerns with the Nursing Home Administrator and Director of Nursing during an interview on December 13, 2023, at 2:30 PM.
Observation of the East Side Nursing Unit nutrition closet on December 14, 2023, at 1:30 PM revealed the following:
a cupboard door under the sink had brown colored stains dried on the inside of the door
wooden shelves in the overhead cupboards had debris and grime on the shelves and the wood appeared to be coming off on some areas of the shelving
there was a can of expired fruit with a best by date of December 4, 2023, in the cupboard
a pink wash basin with brown colored dried stains on the inside of it was located on the top of the refrigerator and had a hard oatmeal crème pie in it
the bottom grates below the refrigerator door had a significant build-up of a brown colored and dried substance
there were multiple snacks that had fallen on the ground and were accumulating behind the refrigerator
there was a coffee ground-like substance in a plastic zip bag with no label or use by date located in one of the cupboards
The Nursing Home Administrator and Director of Nursing were notified on December 14, 2023, at 1:30 PM.
28 Pa. Code 201.14 (a) Responsibility of licensee
Jan 2023
13 deficiencies
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 and/or their responsible party received written notice of the facility bed h...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident and/or their responsible party received written notice of the facility bed hold policy at the time of transfer for two of 11 residents reviewed for hospitalization concerns (Residents 68 and 92).
Findings include:
Clinical record review for Resident 68 revealed nursing documentation dated November 24, 2022, at 1:14 PM that indicated the resident was more lethargic. The physician assistant was notified, and new orders were received to send Resident 68 to the emergency room. He was admitted to the hospital for hypercarbia (an increase in carbon dioxide in the blood stream) related to his lung function.
Resident 68's clinical record did not contain evidence that the facility provided a written copy of the facility's bed hold policy to Resident 68's responsible party when he was transferred to the hospital on November 24, 2022.
Interview with the Nursing Home Administrator and the Director of Nursing on January 5, 2023, at 2:30 PM confirmed that the facility failed to provide Resident 68's responsible party written notification of the facility bed hold policy at the time of Resident 9's transfer to the hospital.
Clinical record review for Resident 92 revealed that the resident was transferred to the hospital on October 19, 2022, after a change in her condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or resident's responsible party upon transfer out to the hospital.
The surveyor reviewed the above information for Resident 92 with the Director of Nursing on January 6, 2023, at 1:26 PM who confirmed that there was no record of the bed hold notice.
483.15(d)(1)(2) Notice of Bed Hold Policy Before/upon Transfer
Previously cited deficiency 1/21/2022
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
Deficiency F0657
(Tag F0657)
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 promote resident involvement with care plan development for one of one resident reviewed...
Read full inspector narrative →
Based on clinical record review and resident and staff interview, it was determined that the facility failed to promote resident involvement with care plan development for one of one resident reviewed (Resident 48).
Findings include:
During an interview with Resident 48 on January 4, 2023, at 9:16 AM revealed that the resident received letters concerning the date of his care plan conferences and would have liked to attend conferences about his care. Resident 48 reported that he did not attend because he assumed that they would be held in his room because he is dependent on staff to get out of bed. He reported that he did not know where the conferences were held, and no one came to get him.
Clinical record review for Resident 48 revealed he had a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment on August 23, 2022, and an annual MDS assessment on November 2, 2022.
MDS documentation dated November 2, 2022, revealed that the resident had a BIMS (BIMS, Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; a score of 13-15 indicates intact cognitive response) of 15.
There was no documented evidence that Resident 48 attended his last two care plan conferences that were associated with the last two MDS assessments.
The surveyor reviewed the above findings for Resident 48 during an interview with the Nursing Home Administrator on January 5, 2023, at 2:30 PM.
483.21(b)(2)(i)-(iii) Care Plan Timing And Revision
Previously cited 1/21/22
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 211.10(a) Resident care policies
28 Pa. Code 211.12(d)(3) Nursing services
28 Pa. Code 211.11(e) Resident care plan
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care to promote optimal pressure ulcer hea...
Read full inspector narrative →
Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide the highest practicable care to promote optimal pressure ulcer healing for one of six residents reviewed for pressure ulcer concerns (Resident 35).
Findings include:
Interview with Resident 35 on January 3, 2023, at 12:05 PM revealed that he developed a pressure ulcer of his lower back at a hospital before admission to the nursing facility. He reported that it is improving but the dressing changes are done too close together at times. Resident 35 reported his admission date as May 19, 2022.
Review of a late entry skin/wound progress note by a nurse practitioner dated May 26, 2022, at 10:15 AM assessed Resident 35 as having a Stage IV (full thickness skin and tissue loss with exposed or directly felt fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer) sacral (low back) pressure ulcer that measured 32 cm (centimeter) length by 5 cm width by 2.5 cm depth.
Review of the most recent wound evaluation dated December 14, 2022, by the wound care consultant, revealed the sacral ulcer was a healing Stage IV that measured 23.5 cm length by 2.1 cm width x 0.2 cm depth.
Clinical record review for Resident 35 revealed that there was no documented evidence of an assessment of the pressure ulcer or measurements since December 14, 2022.
Review of a physician's order dated October 13, 2022, through November 4, 2022, instructed the nurse to cleanse the sacral pressure ulcer with normal saline solution, pack area with Dakin's solution ½ strength (a diluted solution used as an antiseptic to prevent infection) soaked gauze, apply Dermaseptin (skin protectant) to the peri-wound, over with super absorbent ABD (padded gauze, called abdominal gauze) and secure with tape, every day, and every evening shift.
Review of documentation on Dakin's Solution from the National Library of Medicine, dated September 26, 2022, revealed that it can be applied once or twice daily. The most common side effects include redness, swelling, and skin irritation. One of the main concerns for using Dakin's solution are allergic impaired wound healing, which can occur when using high concentrations (greater than ¼ strength).
Review of a physician's order dated November 5 through November 21, 2022, instructed the nurse to cleanse the sacral pressure ulcer with ½ strength Dakin's solution, pack with calcium alginate (absorbent dressings that turn to gel when drainage is absorbed, to promote wound healing), cover with ABD pad and tape, every day and evening shift.
Review of a physician's order dated November 21, 2022, through December 16, 2022, instructed the nurse to cleanse the sacral pressure ulcer with ¼ strength Dakin's solution, pack with calcium alginate, cover with ABD pad and tape, every day and evening shift for wound care.
Review of a physician's order dated December 17, 2022, to current, instructed the nurse to cleanse the sacral ulcer with Acetic Acid Solution 0.25 percent, pat dry, apply calcium alginate, cover with ABD pad and tape.
Review of a resident concern form from Resident 35 dated October 28, 2022, indicated he reported that his wound care was not done for 24 hours. The findings indicated that the wound care was done by the in-house wound consultant.
Review of a resident concern form from Resident 35 dated October 31, 2022, indicated his wound was not done for the past 24 hours. The Nursing Home Administrator reviewed the TAR (treatment administration record), and it was signed off as completed. The Nursing Home Administrator attempted to call the agency nurse to determine if it was completed and not just signed as completed but was unable to contact her. The resident was instructed to notify staff as soon as possible if not completed.
Review of a nursing note for Resident 35 dated November 24, 2022, at 2:22 PM revealed the RN (registered nurse) received a call from the resident that his treatments were not done in the morning when he wanted it done. The RN explained to the resident that the LPN (licensed practical nurse) was passing medications and would be down to his room in a few minutes.
Review of a nursing note for Resident 35 dated November 24, 2022, at 2:24 PM revealed the RN was called to the resident's room by the LPN as the resident was yelling at her and not allowing her to do the treatments. The resident stated he is to have his treatments done in the morning. The RN explained that the nurse was passing medications and charting between medication passes. The RN explained that the treatments were scheduled to be completed between 7:00 AM - 3 PM shift and they will get done during that shift.
During an interview with Employee 1, registered nurse, on January 5, 2022, at 10:00 AM the surveyor requested documentation times that the dressing changes were completed for Resident 35. The surveyor did not have access to this information. Employee 1 indicated that the EMR (electronic medical record) would not permit review of treatment times before November 21, 2022, for this resident. Employee 1 reported that staff sign off the treatments after completing them.
Review of the provided EMR report for Resident 35's treatments revealed the following dates/time in November and December 2022, when the dressing changes were omitted or were too close together or too far apart as the resident described:
November 23, no day shift dressing change
November 23, at 3:45 PM and November 24, at 2:45 PM (23 hours since last dressing change)
November 24, at 7:30 PM (less than 5 hours between dressing changes)
November 26, at 10:52 PM and November 27, at 2:24 PM (greater than 13 hours since last dressing change)
November 28, at 5:34 PM (three hours since last dressing change)
November 29, at 2:38 PM and November 29, at 6:11 PM (less than four hours since last dressing change)
November 30, at 9:34 PM and December 1, at 2:52 PM (greater than 17 hours since last dressing change)
December 2, at 11:34 PM and December 3, at 1:07 PM (greater than 12 hours since last dressing change)
December 3, at 5:24 PM (less than 5 hours between dressing changes)
December 5, at 6:26 PM and December 6, at 11:36 AM (17 hours between dressing changes)
December 11, at 10:15 PM and December 12, at 2:54 PM (greater than 16 hours between dressing changes)
December 12, at 6:00 PM (three hours between dressing changes)
December 25, at 6:04 PM and December 26, at 3:56 PM (22 hours since last dressing change)
December 26, at 6:45 PM, (less than three hours between dressing changes)
December 27, at 2:05 PM (greater than 18 hours between dressing changes)
December 28, at 3:16 PM (greater than 12 hours between dressing changes)
December 29, at 3:52 PM (greater than 12 hours between dressing changes)
December 29, at 5:49 PM (less than two hours between dressing changes)
December 30, at 6:39 PM and December 31, at 4:10 PM (greater than 19 hours between dressing changes)
December 31, at 5:46 PM (less than two hours between dressing changes)
The facility failed to assess Resident 35's pressure ulcer since December 14, 2022, and promote a wound healing environment by performing the dressing changes too close together or too far apart.
During an interview with the Nursing Home Administrator and Director of Nursing on January 5, 2023, at 2:30 PM the surveyor reviewed the findings for Resident 35. The Director of Nursing reported that the dressing changes were ordered on first shift and second shift, and she is aware that sometimes the dressing changes are done at the end of first shift and the start of second shift. When the surveyor asked what the policy is on dressing changes and frequency, the Director of Nursing said there are no times, they are done by shifts. The surveyor questioned what a reasonable time would be between dressing changes to promote wound healing. The Director of Nursing said that eight hours from the last time would be reasonable. The Director of Nursing reported that the nurse must complete medication passes before doing treatments and each nurse manages the schedule their own way.
483.25(b)(i)(1)(2) Treatment/Services to Prevent/Heal Pressure Ulcer
Previously cited 1/21/22
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 consistent with professional standards of practice for t...
Read full inspector narrative →
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to administer supplemental oxygen consistent with professional standards of practice for three of six residents reviewed (Residents 26, 36, and 94) and failed to store supplemental oxygen equipment per professional standards of practice for two of six residents reviewed (Residents 26 and 36).
Findings include:
According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag.
Clinical record review for Resident 26 revealed a diagnoses list that included chronic respiratory failure with hypoxia (blue discoloration of the skin that may result from poor oxygenation), chronic obstructive pulmonary disease (COPD, chronic disease of the lungs that can impede airflow), and unspecified asthma (a lung disease that causes the air passages of the lungs to narrow).
Clinical record review for Resident 26 revealed current physician orders dated December 12, 2022, that instructed staff to administer oxygen but did not specify a flow rate, and to change the oxygen tubing and humidifier bottle weekly.
A current care plan for Resident 26 indicated the resident has a potential for an altered cardiovascular status related to heart disease, hypertension, and hypotension. It instructed staff to administer oxygen via nasal prongs at five liters per minute (LPM) continuously as ordered.
Observation of Resident 26's room on January 3, 2023, at 11:11 AM revealed an unbagged nasal cannula (medical tubing with two nasal prongs used to deliver supplemental oxygen into the nose) and a nebulizer (a medication delivery device used to inhale certain medications) draped across a recliner. The oxygen delivery devices were not in use. An undated gallon of distilled water was observed on the floor behind the recliner next to the oxygen concentrator.
Observation of Resident 26's room on January 4, 2023, at 10:32 AM again revealed an unbagged nasal cannula draped across a recliner in the room. It was not in use. A concurrent interview with Employee 4, licensed practical nurse (LPN), revealed the cannula should be placed in a protective bag when not in use.
Further observation of Resident 26's room revealed a black colored oxygen concentrator that had a significant build-up of dust on it. There was also a significant build-up of dust and debris on the floor surrounding the oxygen concentrator. A concurrent interview with Employee 4 revealed that it was unknown when the area was cleaned last. An undated gallon of distilled water that was one-quarter of the way filled remained on the floor behind the recliner. Employee 4 revealed the water is used for humidification of the resident's oxygen because he is on continuous oxygen and goes through it so fast. It was unknown when the gallon of distilled water was opened, and Employee 4 revealed the water should be dated to indicate when opened.
There was a plastic humidification bottle attached to Resident 26's oxygen concentrator that had a hand-written date of 11/14. Another small container of water was in a plastic basin on the floor next to the oxygen concentrator and identified as prefilled humidification per the manufacturer's label. The prefilled humidification had a hand-written date marked on it as 12/5. The findings were reviewed with Employee 4 who proceeded to change the humidification bottle.
Observation and concurrent interview with Resident 26 on January 5, 2023, at 9:06 AM revealed the resident is on oxygen via nasal cannula. The resident was in the cafeteria and noted to be on portable oxygen. The resident's flow rate was set at two liters per minute. The resident verbalized he is supposed to be on four liters per minute supplemental oxygen, but only uses two when using portable oxygen. These varying flow rates were not addressed in the physician orders or care plan.
Clinical record review for Resident 36 revealed a diagnosis that indicated the resident was dependent on supplemental oxygen.
A current care plan for Resident 36 revealed the resident has a history of COPD and is on supplemental oxygen via nasal cannula at four liters per minute continuously.
Clinical record review for Resident 36 revealed a current physician's order dated November 30, 2022, that instructed staff to administer supplemental oxygen at four liters per minute continuously via nasal cannula.
Observation of Resident 36 on January 3, 2023, at 11:07 AM revealed the resident was receiving oxygen via nasal cannula at a flow rate of 2.5 liters per minute and not at the flow rate as indicated in the physician's order.
Observation of Resident 36 on January 3, 2023, at 1:03 PM revealed an additional nasal cannula draped across the back of the resident's wheelchair located in Resident 36's room next to the bed. The nasal cannula was not in use and unbagged.
Observation of Resident 36 on January 4, 2023, at 10:38 AM revealed the resident was on supplemental oxygen via nasal cannula at a flow rate of three liters per minute. Resident 36 verbalized the flow rate is supposed to be at four. A nebulizer mask was observed not in use and unbagged on the resident's dresser next to the bed. An additional nasal cannula was again observed unbagged and draped over the back of the resident's wheelchair. A concurrent interview with Employee 4 confirmed the findings and revealed that Employee 4 was unsure what the liter per minute flow rate should be and will have to check the order.
Clinical record review for Resident 94 revealed a diagnosis that indicated the resident was dependent on supplemental oxygen.
A current care plan for Resident 94 revealed the resident is on oxygen therapy related to COPD. The care plan instructed staff to administer supplemental oxygen at four liters per minute continuously via nasal prongs.
Clinical record review for Resident 36 revealed a current physician's order dated October 19, 2022, that instructed staff to administer supplemental oxygen at four liters per minute continuously via nasal cannula.
Observation of Resident 94 on January 4, 2023, at 9:55 AM revealed the resident was receiving supplemental oxygen via nasal cannula at a flow rate of 3.5 liters per minute and not at the flow rate as indicated in the physician's order.
The above findings were reviewed in an interview with the Nursing Home Administrator and Director of Nursing on January 5, 2023, at 2:00 PM.
483.25 Respiratory/Tracheostomy Care and Suctioning
Previously cited 1/21/22
28 Pa. Code 211.10 (c) 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
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to provide care consistent with professional standards of practice, for a resident who required dialysis...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to provide care consistent with professional standards of practice, for a resident who required dialysis services for one of one resident reviewed for dialysis concerns (Resident 26).
Findings include:
Clinical record review for Resident 26 revealed a diagnoses list that included dependence on renal dialysis (requires a machine that performs a basic function of the kidney by cleansing the blood of impurities).
A current care plan for Resident 26 indicated the resident needs hemodialysis related to renal failure. The care plan noted the resident received hemodialysis three times a week at a dialysis center.
A review of the current physician orders for Resident 26 revealed no orders related to the assessment of the resident's left arm fistula (surgically created connection between an artery and a vein to provide an access for hemodialysis).
A review of the dialysis paperwork for Resident 26 from the most recent dialysis center visits revealed the resident's left arm fistula was being accessed to provide dialysis.
Clinical record review for Resident 26 for the past 30 days revealed no documentation that staff had assessed the fistula, which included palpating the thrill (to feel for a vibration to indicate blood flow) and auscultation (listen with a stethoscope) the bruit (sound produced by blood flow) of the fistula.
Review of Resident 26's current care plan did not include assessing the resident's dialysis fistula for a thrill or bruit.
The facility failed to provide appropriate assessment for the dialysis fistula for Resident 26.
The findings regarding Resident 26's dialysis fistula were confirmed during an interview with the Director of Nursing on January 6, 2023, at 11:35 AM.
28 Pa. Code 211.11 (c)(d) Resident care plan
28 Pa. Code 211.12 (d)(1)(5) Nursing services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on review of staff education records and staff interview, it was determined that the facility failed to ensure 12 hours of nurse aide in-service education was achieved for one of three employees...
Read full inspector narrative →
Based on review of staff education records and staff interview, it was determined that the facility failed to ensure 12 hours of nurse aide in-service education was achieved for one of three employees reviewed (Employee 2).
Findings include:
Review of staff education records revealed that Employee 2, nurse aide, only completed 3.5 hours of training for the year 2022.
Interview with the Nursing Home Administrator on January 6, 2023, at 8:30 AM confirmed the above findings for Employee 2.
483.35(d)(7) Nurse Aide Perform Review-12 Hr/yr In-Service
Previously cited 1/21/22
28 Pa. Code 201.20(a)(c) Staff development
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0808
(Tag F0808)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide a physic...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide a physician ordered therapeutic diet for one of 23 residents reviewed (Resident 26)
Findings include:
Clinical record review for Resident 26 revealed a diagnoses list that included type two diabetes (high blood sugar caused by an insufficient production of insulin), morbid obesity, moderate protein-calorie malnutrition, nutritional anemia (deficiency of blood cells caused by diet), hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities) and hyperglycemia (high blood sugar).
A current care plan for Resident 26 indicated the resident had a nutritional problem related to morbid obesity, history of hyperkalemia (high potassium levels), end-stage renal disease (an advanced state of kidney disease), open areas, heart failure, and is on a therapeutic diet. The care plan instructed staff to provide and serve the diet as ordered and for the registered dietician to evaluate and make diet change recommendations. The care plan did not specify the therapeutic diet.
A review of the current physician orders for Resident 26 revealed no current diet order for the resident.
A review of the current Medication Administration Record for January 2023 reviewed the diet banner was blank, which indicated no ordered therapeutic diet.
Observation and concurrent interview with Resident 26 on January 5, 2023, at 9:06 AM revealed the resident was eating breakfast in the facility's main cafeteria. The resident reported he eats a lot and needs larger portions. The resident had eaten his main entrée, which he verbalized were eggs and was currently eating two bowls of cereal.
A meal ticket with Resident 26's tray indicated the resident was being served a liberated renal NAS (no added salt), LCS (low concentrated sweets), and large portions.
Further review of Resident 26's clinical record revealed the [NAME] (an informational device that includes pertinent resident information used for care) noted the following regarding eating: Aspiration precautions. Regular diet. Thin liquids. Small bites. Take drinks.
Clinical record review for Resident 26 revealed a Nutrition/Dietary note dated December 13, 2022, at 6:12 PM that indicated the resident was receiving a low concentrated sweets, renal diet, with regular level seven texture and thin liquids.
Based on review of Resident 26's clinical record and lack of physician order for a diet, it was unclear what diet the resident was to receive.
The above information was reviewed with the Nursing Home Administrator and Director of Nursing on January 4, 2023, at 2:00 PM. Further interview with the Director of Nursing on January 5, 2023, at 11:30 AM revealed the diet was not re-entered as an order when the resident returned from a hospital leave on December 12, 2022. The Director of Nursing indicated it was overlooked.
28 Pa. Code 211.10(c) Resident care policies
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 select facility policies and procedures, clinical record review, and responsible party and staff interviews, it was determined that the facility failed to implement an infection con...
Read full inspector narrative →
Based on review of select facility policies and procedures, clinical record review, and responsible party and staff interviews, it was determined that the facility failed to implement an infection control program to prevent the potential spread of infection for one of one resident reviewed (Resident 9).
Findings include:
The facility policy entitled, Scabies, last reviewed without changes on December 12, 2022, indicated that the purpose is to use treat and prevent the spread of scabies (a contagious itchy skin condition caused by a tiny burrowing mite) to other residents, staff, and visitors. The policy indicated that residents suspected of or diagnosed with scabies should follow contact precautions (interventions implemented when a resident has a type of bacteria, virus, skin issue, or sore that can be spread to someone else if that person touches the infected individual or surfaces or equipment near the infected person) for a period of 24 hours after the last treatment. Cleaning protocols for day one for the resident's environment included to wash the cubicle curtain, remove all the bed linen except the pillow, place bed linen in a bag, and take it to the laundry, disinfect the mattress, disinfect the pillow if cover is plastic, if cloth place in dryer on hot cycle and tumble dry, wash and disinfect the bed, bedside table, nightstand, (inside and out), closet, windowsills, and bathroom. The resident should wear facility gowns while he/she is being treated. If the resident is presumed or diagnosed with scabies their clothing will be placed in a bag, and the bag will be sent to laundry for processing. If the resident has stuffed animals, they will be placed in a bag and sent to laundry for processing. Items sent to laundry will be stored in a container/box and kept in a designated area. They will be returned to the room after treatment is completed and the resident is off isolation.
The facility policy entitled, Isolation Steps: Categories of Transmission Based Precautions, last reviewed without changes on December 12, 2022, indicated that contract precautions would be implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contract with the resident or indirect contract with environmental surfaces or resident-care items in the resident's environment.
Clinical record review for Resident 9 revealed a progress note dated January 1, 2023, at 4:17 PM that indicated the resident's daughter reported a rash forming on her chest. The nurse assessed Resident 9 and noted redness reaching from shoulder to shoulder. The nurse notified the on-call physician at this time.
Further clinical record review for Resident 9 revealed a nursing progress note dated January 1, 2023, at 4:47 PM that indicated a new order was received for permethrin cream 5 percent to be put on resident at bedtime and washed off eight hours later. Further clinical record review of Resident 9's medication administration record revealed that the cream was applied on January 1, 2023, at 11:44 PM, and Resident 9 was given a shower on January 2, 2023, at 12:25 PM.
A nursing progress note dated January 6, 2023, at 1:07 PM revealed that Resident 9 was complaining of itching on her scalp and her shoulders/chest area, and the concerns were to be added to the physician's list so that they could see her.
Observation of Resident 9 on January 3, 2023, at 10:30 AM revealed she was sitting in the doorway to her room. There was a sign for contact precautions on her door and appropriate personal protective equipment was noted in and over the door storage.
Interview with Resident 9's responsible party on January 3, 2022, at 11:00 AM revealed concerns related to Resident 9 having scabies. The responsible party revealed that on January 1, 2023, she noted a rash on her mother that was on her chest and back and that it looked just like when she had scabies before. She also voiced concerns that Resident 9 was treated for scabies, but her laundry was never taken care of and removed from the room, and the room was never deep cleaned as it was when Resident 9 had scabies in the past. She voiced concern that the scabies will never go away if the protocol is not followed.
Interview with the Director of Nursing and the Nursing Home Administrator on January 4, 2023, at 9:30 AM revealed that Resident 9 was on contact precautions for an infection in her urine. When asked if she was on precautions related to scabies they indicated no, she doesn't have scabies. They could not provide evidence that Resident 9's rash was determined not to be scabies. They also confirmed that the facility did not deep clean Resident 9's room and that her clothing and other items were never removed from the room per protocol.
The facility failed to implement an infection control program to prevent the potential spread of and infection.
483.80(a)(1)(2)(4)(e)(f) Infection Prevention & Control
Previously cited deficiency 1/22/22 and 10/26/22
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
Based on clinical record review and resident and staff interview, it was determined the facility failed to provide activities of daily living assistance for resident's dependent on staff assistance fo...
Read full inspector narrative →
Based on clinical record review and resident and staff interview, it was determined the facility failed to provide activities of daily living assistance for resident's dependent on staff assistance for three of four residents reviewed for activity of daily living concerns (Residents 35, 37, and 162).
Findings include:
During an interview with Resident 35 on January 3, 2023, at 12:03 PM the resident reported that he prefers bed baths. He reported that he is not always washed up, and sometimes the agency staff do not wash him or give him a bed bath until 12:00 PM or 1:00 PM, and some agency staff give him a washcloth and they don't use a wash basin with soap and water. He reported the reason being is that staff are too busy.
Review of Resident 35's quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated November 16, 2022, documentation revealed that he required extensive assistance from staff for bathing.
Review of Resident 35's task documentation for bathing from November 1 through November 30, 2022, revealed the resident received bed baths on November 3, 7, 10, 17, and 28, 2022. Resident 35 was scheduled for bed baths on November 21 and November 24, 2022. There was no documented evidence that the resident received or refused bed baths on these dates resulting in a 10-day period without a bed bath.
Review of Resident 35's task list for December 1 through December 31, 2022, revealed the resident received bed baths on December 1, 5, 8, 19, 25, and 29, 2022. He was scheduled for bed baths on December 12, 15, and 22, 2022. There was no documented evidence that the resident received or refused bed baths on these dates resulting in a 10-day period and a five-day period without bed baths.
The above findings for Resident 35 were reviewed with the Nursing Home Administrator and Director of Nursing on January 5, 2022, at 2:30 PM.
Observation and interview with Resident 37 on January 3, 2023, at 1:42 PM revealed that the resident's hair was greasy. The resident reported that she likes her hair clean.
Review of Resident 37's quarterly MDS documentation dated December 7, 2022, revealed the resident required extensive assistance of two staff for personal hygiene. Bathing did not occur during this assessment period.
Review of the shampoo task documentation for Resident 37 revealed that she last had a shampoo on December 29, 2022.
The above findings for Resident 37 were reviewed with the Nursing Home Administrator and Director of Nursing on January 4, 2023, at 2:20 PM.
Clinical record review for Resident 162 revealed the facility admitted him on December 22, 2022, with a diagnosis of quadriplegia (paralysis of all extremities). Review of Resident 162's December 2022 and January 2023 task intervention (an action intended to improve the resident's health and comfort) revealed that staff was to provide oral care (brushing teeth) on day, evening, and night shifts. There was no documentation that staff provided oral care or indicated that oral care was not provided during their assigned shift on the following dates:
December 23, 24, 26, and 27, 2022, day shift
December 22, 23, 24, 25, 27, 29, 30, and 31, 2022, evening shift
December 22, 23, 25, 26, 27, 28, 29, 30, and 31, 2022, night shift
January 2, 2023, day shift
January 1 and 2, 2023, evening shift
January 2, 2023, night shift
Interview with Resident 162 on January 3, 2023, at 11:25 AM and January 4, 2023, at 11:24 AM confirmed that staff are not providing oral care and/or brushing his teeth.
The above findings for Resident 162 were reviewed during an interview with the Nursing Home Administrator and Director of Nursing on January 4, 2023, at 2:00 PM.
The facility failed to provide dependent residents with oral care, shampoos, and bathing assistance.
483.24(a)(2) ADL Care Provided for Dependent Residents
Previously cited 11/16/22 and 1/21/22
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on clinical record review, select facility policy review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered inte...
Read full inspector narrative →
Based on clinical record review, select facility policy review, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered interventions for one of 23 residents reviewed (Resident 59), assessment and treatments of non-pressure wounds for one of three residents reviewed (Resident 48), and glucose monitoring and insulin administration for two of three residents reviewed (Residents 35 and 48).
Findings include:
A review of the current physician orders for Resident 59 revealed an order dated September 12, 2022, that instructed staff to utilize geri-sleeves (a type of sleeve worn to help protect the arms from injuries) and to remove for hygiene and when soiled.
A review of the current care plan for Resident 59 revealed the resident has a potential for skin breakdown. An intervention included geri-sleeves as ordered.
Observation of Resident 59 on January 3, 2023, at 11:07 AM revealed the resident was sitting in a wheelchair in his room. The resident was wearing a short-sleeved shirt with no noted geri-sleeves. A large scab was located on his left elbow/forearm area.
Observation of Resident 59 on January 5, 2023, at 10:00 AM revealed the resident was sitting in his wheelchair in a short-sleeved shirt. A kerlix wrap was noted on his left elbow. The resident did not have geri-sleeves on. Employee 4, licensed practical nurse (LPN), verbalized that sometimes the resident takes the geri-sleeves off and throws them on the floor. There were no geri-sleeves located on the floor or in the bathroom of the resident's room.
An interview with Employee 5, nurse aide, on January 5, 2023, at 10:07 AM revealed the geri-sleeves for Resident 59 could not be found in the resident's room. Employee 5 further reported that she never saw him wear geri-sleeves.
There was no clinical documentation to indicate that Resident 59 had refused the geri-sleeves, taken them off, staff removed them, or applied them.
The above information was reviewed in a meeting with the Nursing Home Administrator and Director of Nursing on January 5, 2023, at 2:00 PM. A handwritten note dated January 5, 2023, at 4:51 PM from the Nursing Home Administrator indicated that the geri-sleeves were located in the laundry and the resident was given a new pair and an extra pair.
Review of the facility policy entitled Administering Medications, last reviewed December 2, 2022, indicated that medications may not be prepared in advance and must be administered within one hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).
During an interview with Resident 35 on January 3, 2023, at 10:02 AM, it was revealed that there are times he does not get his glucometer (sample of blood taken from finger to determine glucose level and the amount of insulin needed) and insulin until after meals when they are ordered before meals.
Review of a physician's order for Resident 35 dated November 17, 2022, revealed the nurse was to monitor the resident's blood sugar before meals and at bedtime and administer Novolog FlexPen Solution Pen-Injector (insulin, a medication to lower blood sugar) 100 units/milliliter and inject as per the following sliding scale:
If blood sugar is 0-150, give no insulin
51-200, give 2 units
201-250, give 4 units
251-300, give 6 units
301-350, give 8 units
351-400, give 10 units
401-450, give 12 units subcutaneously (injected below the skin), at 7:30 AM, 11:30 AM, 4:30 PM and 9:00 PM.
Review of the meal tray delivery schedule provided by the facility indicated the meals times served on the hallway where Resident 35 resided were delivered as follows:
Breakfast at 8:10 AM
Lunch at 12:00 PM
Supper at 4:35 PM
Review of Novolog FlexPen Injector administration records for Resident 35 revealed that glucose monitoring was performed, and Novolog FlexPen Injector Insulin was administered on the following times after meals in December 2022:
December 1, at 9:09 AM
December 2, at 9:27 AM, 12:44 PM, and 5:35 PM
December 4, at 12:57 PM
December 6, at 12:46 PM
December 8, at 9:51 AM and 1:10 PM
December 9, at 5:54 PM
December 10, at 10:29 AM and 1:42 PM
December 11, at 9:49 AM and
December 12, at 1:11 PM
Review of a physician's order for Resident 48 dated September 26, 2022, indicated the nurse was to administer Lantus SoloStar Solution Pen-Injector (insulin, to reduce blood sugar) 100 units/milliliter, 34 units subcutaneously two times a day at 9:00 AM and 9:00 PM.
Review of a physician's order for Resident 48 dated November 17, 2022, indicated the nurse was to monitor the resident's blood glucose and administer Novolog FlexPen Solution Pen-Injector 100 units/milliliter subcutaneously before meals and at bedtime, at 7:30 AM, 11:00 AM, 4:00 PM, and 9:00 PM.
Review of the meal tray delivery schedule provided by the facility indicated the meals times served on the hallway where Resident 48 resided were delivered as follows:
Breakfast at 8:35 AM
Lunch at 12:35 PM
Supper at 5:00 PM
Review of Lantus SoloStar Pen-Injector administration records for Resident 48, indicated the insulin was administered on the following times out of compliance in December 2022:
December 1, at 11:08 AM for 9:00 AM dose
December 22, at 10:13 AM for 9:00 AM dose
Review of Novolog FlexPen administration records for Resident 48, indicated the glucose monitoring was performed after meals and the insulin was administered on the following times after meals in December 2022:
December 1, at 11:08 AM for routine dose of 4 units and as needed dose of 2 units for blood glucose of 161 mg/dL (milligrams per deciliter, ordered for 7:30 AM dose)
December 1, at 12:29 PM for routine dose of 4 units and as needed dose of 2 units for blood glucose of 166 mg/dL(ordered for 11:00 AM and administered under 1.5 hours of previous dose)
December 10, at 8:48 AM for routine dose of 4 units and as needed dose of 2 units for blood glucose of 172 mg/dL
December 10, at 1:17 PM for routine dose of 4 units and as needed dose of 2 units for blood glucose of 152 mg/dL
December 18, at 12:53 PM for routine dose of 4 units and as needed dose of 2 units for blood glucose of 177 mg/dL
During an interview with Employee 1, assistant director of nursing, on January 5, 2023, at 10:00 AM confirmed the findings for Residents 35 and 48's blood glucose monitoring and insulin administration.
During an interview with Resident 48 on January 4, 2023, at 9:37 AM it was revealed that he has wounds on his legs and his dressing changes do not always occur. The resident could not remember any details of when his dressing was not changed.
Review of a physician's order dated December 9, 2022, revealed an order that instructed the nurse to cleanse the left lower leg wound with 1/4 strength Dakin's (a cleansing solution used to prevent infection) moistened gauze, pat dry, apply honey fiber (a fiber dressing containing Medi-Honey to aide in removal of dead tissue and promote healing) to open areas, and cover with Kling (a wrap-type bandage) every dayshift.
Review of a wound consultation for Resident 48 dated December 14, 2022, revealed the resident had two vascular (a wound that develops due to a circulation problem) wounds as measured below:
Left lateral lower extremity (leg), 8.5 cm (centimeters) length by 1 cm width by 0.5 cm depth (Measurements were converted to millimeters by the surveyor to correspond with facility documentation, 85 mm by 10 mm by 5 mm)
Left anterior lower extremity, 1.6 cm length by 0.4 cm width by 0.2 cm depth (16 mm by 4 mm by 2mm)
During an observation of a dressing change for Resident 48 on January 5, 2023, at 10:46 AM by Employee 3, licensed practical nurse, it was revealed that the dressing on the resident's leg was dated and initialed as last changed on January 3, 2023. After Employee 3 removed the Kling bandage, a white non-adherent dressing was present with an orange-brown substance that resembled Medi-Honey gel. Employee 3 confirmed it was Medi-Honey gel and not the Medi-Honey fiber dressing.
Review of a Treatment Administration Record for Resident 48 dated January 2023 revealed that the above dressing change was not signed as completed on January 4, 2023.
The surveyor informed the Director of Nursing on January 5, 2023, at 11:30 AM of Resident 48's leg wound dressing that was not performed, and the incorrect dressing was used.
Clinical record review for Resident 48 revealed there were no documented wound assessments since December 14, 2022, until January 6, 2023, after the surveyor asked for assessments on January 5, 2023, at 2:30 PM and again on January 6, 2023, at 10:38 AM.
Review of a Wound Weekly Observation Tool dated January 6, 2023, revealed the following measurements:
Wound 1, left lateral lower extremity, 41 mm length by 13 mm width x 3 mm depth
Wound 2, left anterior lower extremity, 10 mm length by 10 mm width x 0 mm depth
During an interview with the Director of Nursing on January 6, 2023, at 10:38 AM it was revealed that the wound consultant quit and no one in the facility knew of that until recently. The surveyor questioned as to who assesses and manages wounds on a weekly basis other than the consultant and was told there is no system in place at the time as most of the administrative staff are new.
The facility failed to provide wound assessments of non-pressure wounds and follow physician orders regarding treatments.
483.25 Quality of Care
Previously Cited 9/16/22 and 1/21/22
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 F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's rang...
Read full inspector narrative →
Based on review of select facility policies, clinical record review, and staff interview, it was determined that the facility failed to provide physician ordered services to maintain a resident's range of motion for two of four residents reviewed (Residents 43 and 57).
Findings include:
Review of the facility policy entitled, Restorative Nursing, last reviewed without changes on December 12, 2022, revealed that the facility will provide a restorative nursing program with interventions that promote the resident's ability to adapt and adjust to living as independently. The restorative program is found in the clinical record and care plan. The restorative record is initialed as programs are completed daily.
Clinical record review for Resident 43 revealed that therapy staff discharged her on December 21, 2022, with recommendations for her to utilize a left elbow extension splint from breakfast time and doff (remove) at lunch time. A current physician's order for her to utilize a left elbow extension splint from breakfast time and doff at lunch time as needed (PRN), not daily per therapy's recommendations.
Observation of Resident 43 on January 4, 2023, at 9:11 AM, 9:54 AM, and 11:31 AM revealed that she was not wearing a left elbow splint.
Interview on January 4, 2023, at 2:15 PM with the Nursing Home Administrator (NHA) and Director of Nursing (DON) revealed that staff should follow the therapy recommendations to apply Resident 43's left elbow splint daily. They indicated that Resident 43's physician's order for her left elbow splint was input/ordered incorrectly. Staff should have ordered the left elbow splint daily per the therapy recommendations, not PRN. The DON corrected the left elbow splint order after identified by the surveyor
Further review of therapy staff discharge recommendations dated December 21, 2022, revealed that Resident 43 was to continue with current PROM (passive range of motion, staff complete ROM for resident, movement of the body in an attempt to maintain a resident's ability) of bilateral upper extremities in all joints. Review of Resident 43's task intervention (an action intended to improve the resident's health and comfort) dated November 30, 2022, revealed that staff are to complete PROM to her bilateral upper extremities (shoulder, elbows, and wrists) and bilateral lower extremities (hips, knees, and ankles) for 5 repetitions 2 sets twice a day.
Review of Resident 43's PROM task documentation from November and December 2022, and January 2023 revealed that staff documented either 0 (zero) minutes or did not document that they completed her PROM on the following dates:
November 5, 6, 11, 12, 13, 14, 16, 19, 20, 21, 25, 26, and 27, 2022, day shift
November 10, 11, 15, 18, 19, 24, 26, and 29, 2022, evening shift
December 3, 4, 17, 18, 24, and 25, 2022, day shift
December 2, 6, 8, 9, 16, 23, and 27, 2022, evening shift
The surveyor reviewed the above information on January 4, 2023, at 2:15 PM with the Nursing Home Administrator and Director of Nursing.
Clinical record review for Resident 57 revealed that he was to receive active range of motion program (AROM, staff monitor the action, but the resident completes the ROM without hands on assistance) of both lower extremities all areas for three sets of 10 repetitions.
Review of Resident 57's AROM task documentation from November 22, 2022, through January 4, 2023, revealed that staff failed to document program completion on the following dates:
November 28, 29, 30
December 3, 4, 8, 10, 11, 13, 15, 16, 17, 18, 19, 21, 22, 23, 25, 27, 28, and 29
January 2, 2023
Interview with the Nursing Home Administrator and Director of Nursing confirmed the above noted findings related to Resident 57's AROM program during a meeting on January 5, 2023, at 2:40 PM.
483.25(c)(1)-(3) Increase/prevent Decrease In Rom/mobility
Previously cited 1/21/22
28 Pa. Code 211.10(a)(c)(d) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 and resident interview, it was determined that the facility failed to implement interv...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to implement interventions to care for and monitor a resident's urinary catheter for one of three residents reviewed (Resident 162) and care for and monitor a resident's colostomy for one of two residents reviewed (Resident 162).
Findings include:
Clinical record review for Resident 162 revealed that he was admitted on [DATE], with a urinary catheter and colostomy (a surgical opening in the abdominal wall to remove fecal material from the large or small bowel).
Review of Resident 162's task interventions (an action intended to improve the resident's health and comfort) revealed that staff was to provide ileostomy (a surgical opening in the abdominal wall to remove fecal material from the small bowel) care. Empty bag and clean as needed on day, evening, and night shift. Review of Resident 162's December 2022 and January 2023 task documentation revealed that staff did not provide ileostomy care to Resident 162 on the following dates:
December 29, 30, 31, 2022, evening shift
December 29, 2022, night shift
January 2, 2023, day shift
January 1, 2023, evening shift
Further review of Resident 162's task interventions revealed that staff was to provide urinary catheter care and document the urinary catheter output on day, evening, and night shift. Review of Resident 162's December 2022 and January 2023 task documentation revealed that staff did not provide urinary catheter care to Resident 162 on the following dates:
December 29, 30, and 31, 2022, evening shift
January 1, 2023, evening shift
January 2, 2023, day shift
Review of Resident 162's December 2022 and January 2023 task documentation revealed that staff did not document the urinary catheter output for Resident 162 on the following dates:
December 29 and 31, 2022, day shift
December 29, 30, and 31, 2022, evening shift
January 1, 2023, evening shift
January 2, 2023, day shift
Interview with Resident 162 on January 3, 2023, at 11:25 AM confirmed that staff were not monitoring or providing care to his ileostomy. He revealed that the bag or wafer would blow off resulting in him lying in fecal (bowel) material.
The above information was reviewed with the Nursing Home Administrator on January 5, 2023, at 10:30 AM.
483.25(d)(1)(2) Bowel/bladder Incontinence, Continence, UTI
Previously cited 11/23/22 and 1/21/22
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
MINOR
(B)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to notify a residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to notify a resident and responsible party in writing of a transfer to the hospital for four of 11 residents reviewed (Residents 68, 95, 7, and 92).
Findings include:
Clinical record review for Resident 68 revealed that he was transferred to the hospital and admitted on [DATE], for acute respiratory failure. There was no evidence a written notice of transfer was provided or mailed to the responsible party, which included the required components listed below:
The specific reason for the transfer or discharge
The effective date of the transfer or discharge
The location to which the resident is to be transferred or discharged
An explanation of the right to appeal to the State
The name, address (mail and email), and telephone number of the State entity, which receives appeal hearing requests
Information on how to request an appeal hearing
Information on obtaining assistance in completing and submitting the appeal hearing request
The name, address, and phone number of the representative of the Office of the State Long-Term Care ombudsman
Interview with the Nursing Home Administrator and Director of Nursing on January 5, 2023, at 2:30 PM confirmed that the facility did not have documented evidence that a written notice of transfer was provided for Residents 68 as noted above.
Clinical record review for Resident 7 revealed that they were transferred to the hospital on November 29, 2022, after there was a change in their condition, including an altered mental status. There was no documentation that the facility provided written notification to the resident's responsible party regarding the transfer that included the required components.
Clinical record review for Resident 95 revealed that they were transferred to the hospital on the following dates after there was a change in their condition:
September 28, 2022
October 9, 2022
October 18, 2022
November 6, 2022
There was no documentation that the facility provided written notification to Resident 95 or their responsible party regarding the transfer that included the required components.
The surveyor reviewed the above information for during an interview with the Nursing Home Administrator on January 6, 2023, at 11:19 and 11:21 AM.
Clinical record review for Resident 92 revealed that the resident was transferred to the hospital on October 19, 2022, after there was a change in condition. There was no documentation that the facility provided written notification to the resident or their responsible party regarding the transfer that included the required components.
The surveyor reviewed the above information for Resident 92 with the Director of Nursing on January 6, 2023, at 1:26 PM who confirmed that there was no record of the transfer notice.
483.15(c)(3) Notice Requirements Before Transfer/Discharge
Previously cited deficiency 1/21/2022
28 Pa. Code 201.29(a) Resident rights
28 Pa. Code 201.14 (a) Responsibility of licensee
Nov 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
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 interview it was determined that the facility failed to provide consiste...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview it was determined that the facility failed to provide consistent incontinence care for one of three residents reviewed (Resident 13).
Findings include:
Observation on November 22, 2022, at 12:10 PM of west hall nursing unit revealed a strong urine odor. The odor was confirmed with Employee 1, nurse aide. Employee 1 was passing ice water and attempted to find the cause of the odor.
The surveyor left the unit and returned at 12:20 PM and Employee 1 explained the odor was coming from Resident 13's room. Concurrent observation of Resident 13 revealed she was in the bathroom located in her room. Her wheelchair had urine on top of the seat, on the floor beneath the wheelchair, and there was a puddle of liquid on the floor in the middle of the room covering two floor tiles. Employee 1 reported that she saw the therapist with Resident 13, and he took her to the bathroom about 10:00 AM so she didn't think she would get this wet.
During an interview on November 22, 2022, at 12:30 PM with Employee 2, physical therapy assistant, the employee told the surveyor that he provided therapy to the resident and took her to the restroom around 8:20 AM to 8:30 AM.
Clinical record review for Resident 13 revealed a care plan revised on August 31, 2021, which indicated the resident had bladder incontinence and the resident uses disposable briefs. The care plan had a section in which the frequency of the brief change was to be specified, however, the frequency was not specified. The staff were to clean the resident with each incontinence episode.
Review of a 5-day Medicare MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated October 4, 2022, for Resident 13 revealed the resident had a BIMS (Brief Interview for Mental Status, assessment that scores a resident's response to memory questions; a score of zero to seven indicates severe impairment) of five.
The current Visual/Bedside [NAME] Report (summary of basic care instructions for nurse aides) and nurse aide task list for November 2022, did not include instructions on when the staff are to toilet the resident and instructions on when they are to check the resident for incontinence care.
The facility failed to provide clear instructions for staff to care for a cognitively impaired resident's toileting and incontinence needs.
During an interview with the Director of Nursing on November 22, 2022, at 2:30 PM the surveyor reviewed the above findings. The Director of Nursing reported that Resident 13 informs the staff of when she needs to use the restroom. The Director of Nursing confirmed that there was no evidence to indicate a toileting plan or frequency of incontinence checks and placed the resident on a three-day toileting assessment to determine her needs.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
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 provide ordered interventions...
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 provide ordered interventions and timely assessments/interventions from a qualified nutrition professional for residents to promote acceptable parameters of nutritional status resulting in weight loss for one of one resident reviewed for nutrition concerns (Resident CR1). The facility also failed to weigh a resident per physician orders for one of one resident reviewed (Resident CR1).
Findings include:
Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE].
Weight documentation revealed Resident CR1 weighed 175.4 pounds on May 27, 2022, the day after admission to the facility.
A physician's order for Resident CR1 dated May 26, 2022, revealed the nurse was to administer furosemide (diuretic, a medication to rid body of excess fluid) tablet 20 milligrams by mouth every 24 hours as needed for weight gain or edema (puffiness caused by excess fluid in the body tissues).
A physician's order for Resident CR1 dated May 27, 2022, revealed the resident was to be weighed every morning and notify the physician if there is a gain or loss of three pounds in a day or a gain or loss of five pounds in a week. If resident refuses, attempt again on day shift prior to serving breakfast.
Closed clinical record review for Resident CR1 revealed his weights were either documented on the weight record or the MAR (Medication Administration Record, form for charting medication administered).
Clinical record review of CR1's weight documentation revealed that weights were not documented on the following dates and no reasons were indicated as to why the weights were not obtained:
July 12, 14, 16, 18, 19, 20, and 23, 2022
August 3, 5, and 6, 2022
September 3, 7, 11, 12, 15, 21, 25, and 26, 2022
October 1, 5, 14, 17, 23, 27, and 29, 2022
November 1 and 10, 2022
Resident CR1's MARs from June 27 through November 14, 2022, revealed the resident never received furosemide. In addition, the resident was not on any other diuretics.
A Dietary Comprehensive Evaluation dated May 29, 2022, at 9:37 AM for Resident CR 1 revealed that the resident's nutritional care plan needs were for the resident to maintain his weight within 5 percent of 175 pounds and monitor/record/report to physician signs of malnutrition, which included a significant weight loss of 3 pounds in 1 week, greater than 5 percent in 1 month, greater than 7.5 percent in 3 months, and greater than 10 percent in 6 months. The resident was identified as being at risk of malnutrition.
DTR (dietary technician registered) documentation dated June 6, 2022, at 10:39 AM revealed that Resident CR1's daily intake averaged 72 percent of tray food and that pudding was added with lunch and dinner for additional calories.
Clinical record review of CR1's weight documentation revealed that the resident's weight was 161.6 pounds on June 9 and 10, 2022, indicating a 9.1 percent weight loss in 12 days. There was no documented evidence of a nutritional assessment for this weight loss. Review of Resident CR1's weight documentation revealed his weight increased and his weight on June 30, 2022, was 168.6 pounds indicating a 4.42 percent weight loss in one month.
Resident CR1's weight on July 21, 2022, was 161.4 pounds, indicating a 7.98 percent weight loss in less than three months (from admission).
DTR documentation dated July 25, 2022, at 2:14 PM revealed Resident CR1 showed improvement in the H/H (hemoglobin and hematocrit, labs which can indicate anemia, low iron) and the diet remains appropriate. There was no documentation indicating an assessment of significant weight loss and interventions until August 2, 2022, at 1:17 PM (12 days later). This documentation included the resident's weight was 160.6 pounds, which indicated a 7.5 percent weight loss in three months. The resident's diet was liberalized from a Low Sodium Diet (diet with strict salt restriction) to a No Added Salt diet.
DTR documentation dated August 23, 2022, at 2:05 PM revealed Resident CR1's weight was 158.8 pounds. The note indicated that the weight fluctuations were expected as the resident was on diuretics with daily weights and parameters to call the physician. The resident was not taking diuretics.
Clinical record review of a comprehensive dietary evaluation for Resident CR1 dated August 29, 2022, revealed the resident's current weight was 157.5 pounds which was a 9 percent weight loss over three months. The note indicated that weight loss was a goal, and the resident was utilizing diuretics. A dietary supplement of 2 Cal at 60 milliliters was recommended twice daily during medication pass. Clinical record review revealed the resident did not receive any diuretics and this contradicted the May 29. 2022, goal to maintain weight.
DTR documentation dated September 19, 2022, at 11:53 AM revealed Resident CR1's weight was 153.9 pounds with an average meal intake of 66 percent. The resident utilizes 2 CAL twice daily with medication pass. Ice cream was ordered for lunch and dinner for extra calories.
Clinical record review for Resident CR1 revealed there was no documented evidence on the August and September MAR that the 2 Cal supplement was provided until September 15, 2022, 17 days after it was recommended.
Review of weight documentation for Resident CR1 revealed his weight was 156.2 pounds on September 22, 2022.
DTR documentation dated September 22, 2022, at 11:49 AM revealed the DTR recommended the 2 Cal supplement be increased to 60 milliliters four times daily with mediation pass.
Review of a Malnutrition and Morbid Obesity Tool completed by the DTR on October 4, 2022, and signed by the Clinical Nurse Practitioner on October 10, 2022, revealed Resident CR1 was provided the diagnosis of Malnutrition, Severe, protein-calorie malnutrition.
Review of weight documentation for Resident CR1 revealed he continued to lose weight and his weight was 138.8 pounds on October 31, 2022.
Registered Dietitian (RD) documentation for Resident CR1 dated November 1, 2022, revealed there was a physician's order to assess the resident's needs. The RD noted the resident dislikes the 2 Cal supplement. The family was willing to provide Carnation Instant Breakfast drink for the resident as he liked this at home. The 2 Cal was discontinued. The No Added Salt diet was discontinued, and an RED (enhanced protein foods) diet was added and to continue with ice cream at lunch.
RD documentation for Resident CR1 dated November 9, 2022, at 6:09 PM revealed Magic Cup (nutritional supplement) was added to provide additional nutrients.
Clinical record review for Resident CR1 revealed there was no documented evidence of the amount or percentages of the nutritional supplements (2 Cal, Carnation Instant Breakfast) the resident consumed when offered.
Clinical record review for Resident CR1 revealed that the last documented weight was 136.4 pounds on November 9, 2022, which was a 22.35 percent weight loss in under six months since admitted to the facility.
The facility failed to monitor, assess, and implement measures to prevent significant weight loss for Resident CR1.
During an interview with the Nursing Home Administrator on November 22, 2022, at 2:00 PM it was confirmed that the resident was not assessed timely for weight loss, the nutritional supplement was not provided as recommended until 17 days later, the nutritional assessments were inaccurate regarding diuretics, and daily weights were not monitored as ordered. In addition, it was not noted until November 1, 2022, that the resident did not like the 2 Cal supplement and there was no record of how much of this supplement he consumed.
483.25(g)(1)-(3) Nutrition/hydration Status Maintenance
Previously cited 1/22/2022
28 Pa. Code 211.10(c) Resident care policies
Nov 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
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 ob...
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 obtain dental services for one of seven residents reviewed (Resident 2).
Findings include:
Observation of Resident 2 on November 1, 2022, at 2:08 PM revealed he had several natural and missing teeth in his lower jaw. Resident 2 was unable to indicate if he wore a partial denture on the bottom jaw but confirmed that he wore upper dentures. Resident 2 stated that he did not have all his bottom teeth because a dentist took them out and threw them away.
Clinical record review for Resident 2 revealed a plan of care developed by the facility on April 13, 2018, to address Resident 2's potential for oral and/or dental health problems related to an upper denture and lower partial denture and the need for assistance with oral care. The interventions listed in the plan of care included a revision on October 28, 2020, that Resident 2's bottom partial denture was, not in use.
There was no additional information on the plan of care or in Resident 2's medical record progress notes to explain the change in Resident 2's lower denture partial use (e.g., device lost or broken or not tolerated).
Nursing documentation dated September 30, 2020, at 4:21 PM indicated that Resident 2 was to have a dental consult for a fitting of a lower denture.
Nursing documentation dated October 8, 2020, at 6:24 PM again indicated that Resident 2 was scheduled for an appointment at a dental provider on November 5, 2020.
Review of a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], revealed that staff assessed Resident 2 as having minimal difficulty hearing, is only sometimes understood, and that the interview to determine Resident 2's mental status could not be completed as Resident 2 is rarely or never understood. The assessment indicated that Resident 2 had long and short term memory problems and his cognitive skills for daily decision making was severley impaired.
Nursing documentation dated October 26, 2022, at 3:00 PM indicated that the consulting dental provider treated Resident 2.
Review of the consultant dental provider documentation dated October 26, 2022, revealed that Resident 2 could not recall if, or when, he ever wore a partial. The dental provider stipulated that Resident 2 did not have a lower partial denture since seen by him a year and a half ago.
Interview with the Nursing Home Administrator on November 1, 2022, at 12:30 PM revealed that the facility could not determine the condition or existence of Resident 2's lower partial denture, if a consultant dental provider provided services for Resident 2 in November 2020 as planned, or the factors that precipitated the discontinuation of his bottom partial denture on his plan of care in October 2020. The interview confirmed that although Resident 2 is incapable of daily decision making, there was no evidence that Resident 2's responsible party was included in his dental treatment plan during his appointment on October 26, 2022.
483.55(b)(1)-(5) Routine/emergency Dental Services in Nursing Facilities
Previously cited deficiency 1/21/22
28 Pa. Code 211.15(a) Dental services
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, observation, clinical record review, and interviews with staff and r...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, observation, clinical record review, and interviews with staff and residents, it was determined that the facility failed to ensure dependent residents received assistance with bathing for two of seven residents reviewed for activities of daily living concerns (Residents 4 and 3) and for personal hygiene for four of seven residents reviewed (Residents 1, 2, 3, and 5).
Findings include:
The facility policy entitled, Shower/Tub Bath, last reviewed without changes on August 1, 2022, instructed staff to document the date and time the shower/tub bath was performed. If the resident refused the shower/tub bath, document the reasons why and the intervention taken. Report to the supervisor if the resident refuses the shower/tub bath.
An annual MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) assessment dated [DATE], assessed Resident 5 as needing extensive assistance for personal hygiene (which includes combing hair, brushing teeth, shaving, and washing and drying face and hands).
Observation of Resident 5 on November 1, 2022, at 1:00 PM revealed the resident had excess long hair on his neck and face. He had dirty and jagged fingernails. Concurrent interview with Employee 2, nurse aide, confirmed the findings.
Clinical record review for Resident 5 revealed no documented evidence that the resident refused shaving or nail care or has behaviors causing dirty nails.
Clinical record review for Resident 4 revealed the resident was hospitalized from [DATE], through October 3, 2022.
A 5-day Medicare MDS assessment dated [DATE], assessed Resident 4 as requiring the physical assistance of one staff for bathing.
During an interview with Resident 4 on November 1, 2022, at 1:15 PM she indicated she prefers showers over bed baths and has not been provided a shower in a long time.
Review of bathing records for Resident 4 dated October 2022 revealed the resident prefers showers on Tuesdays and Friday evenings and that the staff provided bed baths during October. Clinical record review revealed there was no documented evidence that the resident refused showers or a clinical reason for not providing showers.
A quarterly MDS assessment dated [DATE], assessed Resident 1 as being dependent on two staff for bathing and personal hygiene.
Observation of Resident 1 on November 1, 2022, at 1:20 PM with Employee 1, licensed practical nurse, revealed the resident's toenails were very long.
During an interview with the Nursing Home Administrator on November 1, 2022, at 3:00 PM the surveyor reviewed the findings for Residents 1, 4, and 5. The Nursing Home Administrator revealed that Resident 1 refused the last podiatry (foot doctor for trimming of toenails) consultation and that the nursing staff could cut the residents toenails as the resident does not have any special needs (i.e., diabetes) to see a podiatrist.
Clinical record review for Resident 3 revealed an admission MDS assessment dated [DATE], that assessed him as requiring extensive two-person physical assistance with personal hygiene (to include shaving) and dressing; and two-person physical assistance for bathing (to include showers). The assessment also assessed Resident 3's cognition level as moderately impaired (BIMS, Brief Interview for Mental Status, score of five).
A quarterly MDS dated [DATE], continued to assess Resident 3's cognition level as mildly impaired (BIMS score of 8); and that he remained dependent on the extensive physical assistance of two staff for hygiene, was totally dependent on the physical assistance of one staff for bathing, and required the extensive physical assistance of one staff for dressing.
Observation of Resident 3 on November 1, 2022, at 2:39 PM revealed him to be in bed, in a hospital gown, with several days' beard and moustache growth.
Clinical record review of Resident 3's Task documentation (electronic charting completed by staff to confirm the provision of care) revealed that no staff documented the provision of hygiene assistance on November 1, 2022, until 9:59 PM. There was no indication that the facility provided morning hygiene or dressing assistance for Resident 3 on November 1, 2022.
Review of Task documentation for Resident 3's bathing indicated that Resident 3 preferred a shower on Tuesday and Friday evenings. Documentation reviewed for August, September, and October 2022, revealed that staff documented the provision of a shower on only two occasions in August 2022, zero occasions in September 2022, and two occasions in October 2022. Staff documented the provision of a bed bath for the three months reviewed; however, there was no documented evidence that this was Resident 3's preference or that he refused a shower on each occasion that a bed bath was documented.
Clinical record review for Resident 2 revealed an annual MDS dated [DATE], and a quarterly MDS dated [DATE], that assessed him as requiring the extensive physical assistance of two staff for hygiene.
Observation of Resident 2 on November 1, 2022, at 2:33 PM revealed that his face was not clean shaven.
Clinical record review of Resident 2's Task documentation revealed that no staff documented the provision of hygiene assistance on November 1, 2022, until 9:59 PM. There was no indication that the facility provided morning hygiene assistance for Resident 2 on November 1, 2022.
Interview with Employees 1 and 3 (nurse aide) on November 1, 2022, at 2:39 PM indicated that Resident 3 had no clothes to dress him; and that there was no evidence that either Resident 2 or Resident 3 refused shaving or dressing assistance on this date. Employee 3 stated that she did not receive change-of-shift report from the first shift nurse aide caring for Residents 2 and 3 before she assumed her assignment on this date. Employee 1 instructed Employee 3 to provide Residents 2 and 3 assistance with shaving following the interview.
483.24(a)(2) ADL Care Provided for Dependent Residents
Previously cited 1/21/22
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.11(d) Resident care plan
28 Pa. Code 211.12(d)(1)(5) Nursing services
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 44% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
- • 41 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Milton Rehabilitation And Nursing Center's CMS Rating?
CMS assigns MILTON REHABILITATION AND NURSING CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Milton Rehabilitation And Nursing Center Staffed?
CMS rates MILTON REHABILITATION AND NURSING CENTER'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 Milton Rehabilitation And Nursing Center?
State health inspectors documented 41 deficiencies at MILTON REHABILITATION AND NURSING CENTER during 2022 to 2025. These included: 40 with potential for harm and 1 minor or isolated issues.
Who Owns and Operates Milton Rehabilitation And Nursing Center?
MILTON REHABILITATION AND NURSING CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BEDROCK CARE, a chain that manages multiple nursing homes. With 138 certified beds and approximately 120 residents (about 87% occupancy), it is a mid-sized facility located in MILTON, Pennsylvania.
How Does Milton Rehabilitation And Nursing Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, MILTON REHABILITATION AND NURSING CENTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (44%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Milton Rehabilitation And Nursing Center?
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 Milton Rehabilitation And Nursing Center Safe?
Based on CMS inspection data, MILTON REHABILITATION AND NURSING CENTER 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 2-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Milton Rehabilitation And Nursing Center Stick Around?
MILTON REHABILITATION AND NURSING CENTER 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 Milton Rehabilitation And Nursing Center Ever Fined?
MILTON REHABILITATION AND NURSING CENTER has been fined $9,750 across 1 penalty action. This is below the Pennsylvania average of $33,176. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Milton Rehabilitation And Nursing Center on Any Federal Watch List?
MILTON REHABILITATION AND NURSING CENTER 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.