HARMON HOUSE HEALTH & REHAB CENTER
For profit - Limited Liability company
109 Beds
SABER HEALTHCARE GROUP
Data: November 2025
Trust Grade
10/100
#433 of 653 in PA
Photo by Harmon House Care Center
Photo by Ginger F
Photo by Ginger F
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Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Harmon House Health & Rehab Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. With a state rank of #433 out of 653 facilities in Pennsylvania, they are in the bottom half overall, and #5 out of 18 in Westmoreland County means only four local options are worse. Although the facility's trend is improving, reducing issues from 18 in 2024 to 10 in 2025, there are still serious concerns, including four incidents of neglect that resulted in harm to residents, such as improper transfers leading to falls and injuries. Staffing is a relative strength with a 3/5 star rating and a staff turnover of 41%, which is below the state average, but the facility has also incurred $32,394 in fines, higher than 80% of Pennsylvania facilities, indicating potential compliance issues. Additionally, RN coverage is average, meaning while there are registered nurses available, they may not be as accessible as in higher-rated facilities.
- Trust Score
- F
- In Pennsylvania
- #433/653
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 41% turnover. Near Pennsylvania's 48% average. Typical for the industry.
- Penalties ○ Average
- $32,394 in fines. Higher than 63% of Pennsylvania facilities. Some compliance issues.
- Skilled Nurses ✓ Good
- Each resident gets 42 minutes of Registered Nurse (RN) attention daily — more than average for Pennsylvania. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 48 deficiencies on record. Higher than average. Multiple issues found across inspections.
10/100
Bottom 34%
Review needed
18 → 10 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 18 issues
2025: 10 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (41%)
7 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: 41%
Near Pennsylvania avg (46%)
Typical for the industry
Federal Fines: $32,394
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: SABER HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 48 deficiencies on record
4 actual harm
Jun 2025
7 deficiencies
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 a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for six of 39 residents reviewed (Residents 18, 30, 61, 66, 77, 79).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415F1 (antibiotic medication) was to be checked if the resident received an antibiotic medication during the seven-day look-back period.
Physician's orders for Resident 18, dated April 24, 2025, included an order for the resident to receive 1 gram of Cefipime (antibiotic) intravenously every eight hours for seven days for a urinary tract infection. The resident's Medication Administration Record (MAR's) for April 2025 revealed that the resident received Cefipime every eight hours from April 24 through April 29, 2025; however, a significant change MDS assessment for Resident 18, dated May 3, 2025, revealed that Section N0410F1 was not checked, indicating that the resident did not receive any antibiotic medications during the seven-day look-back period.
Interview with the RNAC on June 5, 2025, at 10:33 confirmed that Section N0410F1 of Resident 18's significant change assessment of May 3, 2025, was not coded correctly.
The RAI User's Manual, dated October 2024, indicated that Section O0110K1 Hospice care (a specialized form of end-of-life care that provides comfort, support, and medical assistance to terminally ill patients and their families) was to be coded to indicate if the resident was receiving hospice services (a) on admission, (b) while a resident or (c) at discharge. Review of Resident 30's clinical record, including physician's orders, care plans and nurses' notes, revealed no documented evidence that the resident was receiving hospice services during the seven-day look-back period; however, a quarterly MDS assessment for Resident 30, dated May 29, 2025, revealed that Section 0O110K1 was coded (b) while a resident, indicating that the resident was receiving hospice services during the seven-day look back-period.
Interview with the Registered Nurse Assesment Coordinator on June 5, 2025, at 9:13 a.m. confirmed that Resident 30's MDS, dated [DATE], was coded inaccurately.
The RAI User's Manual, dated October 2024, revealed that if the resident had an unhealed pressure ulcer (skin impairment caused by pressure), then Section M0210 was to be coded (1) yes, and the number of pressure ulcers was to be coded in Section M0300A for Stage I pressure ulcers (reddened area that does not blanche), Section M0300B for Stage II pressure ulcers (superficial open area or blister), Section M0300C for Stage III pressure ulcers (full thickness skin loss), Section M0300D for Stage IV pressure ulcers (full thickness tissue loss exposing bone, tendons or muscle), Section M0300E for unstageable pressure ulcers related to a non-removable device, Section M0300F for unstageable pressure ulcers due to slough (yellow, tan, or green tissue, usually moist) or eschar (dead tissue this is black or brown in color and may appear scab like), and M0300G for unstageable pressure ulcers related to suspected deep tissue injury (purple or maroon area of discolored intact skin due to damage of underlying soft tissue).
A nursing note, dated May 23, 2025, at 5:08 p.m., revealed that Resident 61 was admitted to the facility and the dressing to the bottom of her left heel was removed for drainage. She had a Stage III open area that measured 4 x 3 x 0.5 centimeters (cm). The area was cleansed with normal saline solution (sterile salt water) and Hydrofera blue (antibacterial wound dressing) was applied to the area and covered with a dressing as ordered; however, an admission MDS assessment for Resident 61, dated May 25, 2025 revealed that Section M0210 was coded no (0), indicating that the resident did not have an unhealed pressure ulcer; therefore, Section M0300C (Stage III) was not coded to indicate that the resident had a Stage III pressure ulcer.
Interview with the RNAC on June 5, 2025, at 10:33 a.m. revealed that she did not think the resident received a treatment to the left heel and that the area was coded as a diabetic ulcer after the assessment period, so it was not coded as a pressure ulcer.
The RAI user's manual, dated October 2024, revealed that Section N0415A Antipsychotic (medication used for behaviors) was to be coded if the resident took the medication during the seven-day look-back period. Physician's orders for Resident 66, dated May 13, 2025, included an order for the resident to receive 150 milligrams of Clozapine (an antipsychotic medication) every day at bedtime. The resident's MAR for May 2025 revealed that the resident received Clozapine daily during the assessment's seven-day look-back period; however, a quarterly MDS assessment for Resident 66, dated May 7, 2025, revealed that Section N0401A was not coded, indicating that the resident did not receive an antipsychotic medication during the seven-day look-back period.
Interview with the RNAC on June 4, 2025, at 3:26 p.m. confirmed that Section N0401A of Resident 66's quarterly assessment of May 7, 2025, was not coded correctly.
The RAI User's Manual, dated October 2024, indicated that the intent of Section N was to record the number of days during the seven days of the assessment period that any type of injection, insulin, and/or select medications were received by the resident. An admission MDS assessment for Resident 77, dated May 21, 2025, revealed that Section N0300 indicated that the resident did not receive an injection during the seven days of the assessment period; however, a review of Resident 77's Medication Administration Record (MAR) for May 2025 revealed that the resident received a PPD (purified protein derivative - skin test for Tuberculosis administered with a needle) on May 15, 2025.
Interview with the RNAC on June 5, 2025, at 10:33 a.m. revealed that she does not code PPD injections.
The RAI User's Manual, dated October 2024, indicated that Section N0415I1 (Antiplatelet Medications - medications used to reduce the risk of blood clots) was to be checked if the resident received an anti-platelet medication during the seven-day assessment period. A care plan for Resident 79, dated March 11, 2025, indicated that the resident was prescribed an antiplatelet. Physician's orders for Resident 79, dated November 7, 2023, included an order for the resident to receive 81 milligrams (mg) of aspirin daily. Review of the resident's Medication Administration Record (MAR) for April and May 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 79, dated May 7, 2025, revealed that Section N0415I1 was coded zero (0), indicating that the resident did not receive an anti-platelet during the last seven days.
Interview with the RNAC on June 4, 2025, at 1:20 p.m. confirmed that Resident 79's MDS assessment was not coded accurately.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect the resident's specific care need...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated/revised to reflect the resident's specific care needs for three of 39 residents reviewed (Residents 30, 77, 91).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 30, dated May 29, 2025, indicated that the resident was cognitively impaired, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine), and had diagnoses that included obstructive uropathy (condition where the flow of urine is blocked within the urinary tract). A care plan for Resident 30, dated January 28, 2025, indicated that the resident had urinary incontinence (the involuntary leakage of urine) and staff were to assess her pattern of urination and episodes of incontinence. A care plan, dated May 12, 2025, indicated that the resident required an indwelling urinary catheter, and that staff were to provide catheter care as ordered.
A nurse's note for Resident 30, dated May 10, 2025, indicated that the resident had an indwelling catheter placed.
An interview with the Licensed Practical Nurse Assessment Coordinator on June 5, 2025, at 12:15 p.m. revealed that Resident 30's care plan was not revised to remove interventions for urinary incontinence when the resident had an indwelling catheter placed and it should have been.
An admission MDS assessment for Resident 77, dated May 21, 2025, indicated that the resident was cognitively impaired, received no anti-psychotic medications, and had diagnoses that included anxiety. Physician's orders for Resident 77, dated May 27, 2025, included an order for the resident's Olanzapine (anti-psychotic medication) to be discontinued. A review of the resident's Medication Administration Record (MAR) for June 2024 revealed that Resident 77 was not receiving an anti-psychotic medication; however, the resident's current care plan indicated that the resident received an antipsychotic medication for anxiety.
An interview with the Director of Nursing on June 5, 2025, at 11:38 p.m. confirmed that Resident 77's care plan was not revised to indicate that the resident's anti-psychotic medication was discontinued.
A quarterly MDS assessment for Resident 91, dated March 19, 2025, indicated that the resident had moderate cognitive impairment, was independent with personal care needs, and had diagnoses that included dementia. A care plan for Resident 91, dated June 24, 2024, indicated that the resident was receiving antipsychotic medication for depression; however, a review of the Medication Administration Record (MAR) for Resident 91, dated May and June 2025, revealed no documented evidence that the resident was receiving antipsychotic medication.
An interview with the Licensed Practical Nurse Assessment Coordinator on June 5, 2025, at 12:13 p.m. confirmed that Resident 91's care plan was not revised to indicate that the resident was not receiving antipsychotic medication and should have been.
28 Pa. Code 201.24(e)(4) admission Policy.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's order for treatments for on...
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Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to clarify a provider's order for treatments for one of 39 residents reviewed (Resident 30).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 30, dated May 29, 2025, indicated that the resident was cognitively impaired, had an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine), had diagnoses that included obstructive uropathy (condition where the flow of urine was blocked within the urinary tract), and had a pressure ulcer.
A wound consult note for Resident 30, dated February 27, 2025, and March 6, 2025, indicated that the resident was to have her wound cleansed with wound cleanser, gently scrubbing to remove all old ointment and any loose tissue, patted dry, have Medi honey (medical-grade honey used to treat wounds) applied to the wound bed, and covered with a dry border gauze dressing (wound dressing that combines an absorbent gauze pad with a wider, adhesive border for secure placement) daily and as needed for soiling or dislodgement.
A wound consult note for Resident 30, dated March 13, 2025, indicated that the resident's prior wound regimen was to be discontinued and that her wound was to be cleansed with 0.125 percent Dakin's Solution (used topically to clean and disinfect wounds and to prevent infection), the wound packed with Dakin's moistened kerlix (type of bandage roll used for wound care) to fill the void and depth, and covered with a dry ABD pad (a type of medical dressing used to absorb fluids and provide padding for wounds) twice a day and as need for soiling or dislodgement.
Review of the Treatment Administration Record (TAR) for Resident 30, dated February and March 2025, indicated that from February 28 through March 20 the resident had treatments completed that included having her sacrum cleansed with wound cleanser, patted dry, Medi-honey applied, and covered with calcium alginate (highly absorbent wound dressings made from natural seaweed fibers and calcium salts) and a large border dressing daily.
Interview with the Infection Control Nurse on June 5, 2025, at 3:39 p.m., in the presence of the Director of Nursing and Nursing Home Administrator, revealed that she does treatments with the wound consultant every week and receives verbal orders for treatment changes during that time. She was responsible for reviewing the wound consultant's notes each week and to identify any discrepancies between the verbal orders he provides her and the recommendations he includes in his notes. She is responsible to clarify any discrepancies. The infection control nurse confirmed that there were discrepancies that she failed to identify and clarify between the treatment orders that were being completed from February 28 through March 20, 2025, and the wound consultant's recommendations.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administr...
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Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders regarding medication administration were followed for one of 39 residents reviewed (Resident 91). This deficiency was cited as past non-compliance.
Findings include:
The facility policy for medication administration, dated August 14, 2024, indicated that medications are prescribed as ordered by the physician and will be administered by certified healthcare professionals in a behavior consistent with appropriate infection control and standards of practice.
A quarterly MDS assessment for Resident 91, dated March 19, 2025, indicated that the resident had moderate cognitive impairment was independent with personal care needs, and had diagnosis that included dementia.
Physician's orders for Resident 91 dated June 20, 2024, included for the resident to receive 25 milligrams (mg) of metoprolol tartrate (used to treat high blood pressure) twice a day and to hold the medication if the resident's systolic blood pressure (SBP-top number on a blood pressure reading) was less than 120 millimeters of mercury (mm/Hg).
Review of the Medication Administration Record (MAR) for Resident 91, dated January through April 2025, indicated that 25 mg of metoprolol tartrate was administered to the resident on January 14 during the a.m. med pass when the resident's SBP was 110 mm/Hg; February 8 during the p.m. med pass when the resident's SBP was 110 mm/Hg; March 1 during the a.m. med pass when the resident's SBP was 116 mm/Hg; March 6 during the a.m. med pass when the resident's SBP was 118 mm/Hg; April 10 during the p.m. med pass when the resident's SBP was 112 mm/Hg; April 15 during the p.m. med pass when the resident's SBP was 112 mm/Hg; April 17 during the p.m. med pass when the resident's SBP was 112 mm/Hg; April 20 during the p.m. med pass when the resident's SBP was 118 mm/Hg; and April 27 during the p.m. med pass when the resident's SBP was 118 mm/Hg.
Interview with the Nursing Home Administrator and Director of Nursing on June 4, 2025, at 4:40 p.m. confirmed that Resident 91 was administered metoprolol tartrate when it should have been held per physician's orders for a SBP less than 120.
Following identification that medications were being administered outside of physician ordered parameters, the facility's corrective actions included:
Residents who had physician-ordered parameters for medication administration were identified.
Education was provided to licensed staff regarding administering medications with parameters and the six rights of medication administration.
Audits were completed three times a week for four weeks to identify any medications that were administered outside of physician-ordered parameters and will continue twice monthly for two months. The findings will be reviewed with the quality assurance performance improvement committee.
A review of the facility's corrective actions revealed that they were in compliance with F684 on May 30, 2025.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to follow infecti...
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Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for one of 39 residents reviewed (Resident 76).
Findings include:
CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.
The facility's policy regarding EBP, dated August 14, 2024, indicated that EBP is intended to prevent transmission of MDRO's via contaminated hands and clothing of healthcare workers to high-risk residents during high contact activities. High-risk residents are those with chronic wounds and indwelling devices (such as central lines, urinary catheters, and tracheostomies (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs) and for all those colonized or infected with a MDRO currently targeted by the CDC. High contact activities that may result in transfer of MDRO's to hands and clothing of healthcare personnel, even when blood and body fluid exposure is not anticipated. These include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, device care or use, and wound care. Residents placed on EBP should remain on EBP for the duration of their stay or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 76, dated March 26, 2025, revealed that the resident was understood, could understand others, had a diagnosis which included End-Stage Renal Disease (ESRD - permanent kidney failure that requires a regular course of dialysis or a kidney transplant), and received dialysis (a type of treatment that helps the body remove extra fluid and waste products from the blood when the kidneys are not able to). A care plan for the resident, dated March 7, 2024, revealed that the resident required dialysis and had a right subclavian (located below your collarbone) dialysis catheter (a medical device used for kidney dialysis, providing access to the bloodstream for the process of cleaning waste and excess fluid from the blood).
Review of Resident 76's clinical record revealed no documented evidence to indicate that the resident was on EBP's due to having the right subclavian dialysis catheter.
Interview with the Infection Control Preventionist on July 31, 2024, at 10:30 a.m. confirmed that there was no documented evidence to indicate that Resident 76 was on EBP's due to having the right subclavian dialysis catheter. She indicated that the resident was on EBP's previously for a wound that the resident had, and once the wound was healed the order for EBP's was discontinued; however, the order for EBP's should not have been discontinued because the resident still needed to be on EBP's due to having the right subclavian dialysis catheter. She indicated that the Director of Nursing advised her that he was placing an order, as well as creating a care plan for EBP's for the resident.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for flushing intravenous (IV) ...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for flushing intravenous (IV) catheters, and/or that intravenous catheters were flushed according to the facility's policy for two of 39 residents reviewed (Residents 54, 61) who had long-term intravenous catheters.
Findings include:
The facility's policy regarding flushing intravenous catheters (a thin tube placed in a vein that can be used for an extended period of time to deliver fluids and/or medications), dated August 14, 2024, revealed that specific flush orders must be obtained, documented and submitted to the pharmacy. Flushing is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. All peripheral vascular access devices are flushed between incompatible medications with normal saline or other flush solution as recommended by the manufacturer.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 54, dated May 19, 2025, revealed that the resident was cognitively intact and was dependent for daily care needs.
Physician's orders for Resident 54, dated May 16, 2025, included orders to insert an IV catheter (a thin, flexible tube that is placed in a vein to administer fluids) and start Normal Saline at 80 milliliters (ml)/hour (hr).
A nursing note, dated May 16, 2025, at 10:00 a.m., revealed that the nursing supervisor was called to Resident 54's room due to a change in condition. Resident 54 was lethargic, was not responsive, and vital signs were within normal limits. The Certified Registered Nurse Practioner (CRNP - a registered nurse with advanced training to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, prescribe medications and formulate treatment plans) was at the bedside and ordered an IV catheter to be inserted with Normal Saline infusing at 80 ml/hr. The IV catheter was inserted without difficulty with excellent blood return and it flushed well.
Review of Resident 54's Medication Administration Records (MAR's) for May 2025 revealed no documented evidence that the IV catheter was inserted, the resident received Normal Saline at 80 ml/hr, or that the IV was flushed.
Interview with the Director of Nursing on June 4, 2025, at 1:57 p.m. confirmed that there was no documented evidence that Resident 54 had an IV inserted with Normal Saline infusing at 80 ml/hr or that the IV was flushed.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated May 25, 2025, revealed that the resident was cognitively intact, had IV access, and received an antibiotic.
Physician's orders for Resident 61, dated May 23, 2025, included orders for staff to flush the resident's midline using 10 ml of 0.9 percent sodium chloride before and after medication administration, followed by 30 units of Heparin three times a day (6:00 a.m., 2:00 p.m., 9:00 p.m.).
Physician's orders for Resident 61, dated May 29, 2025, included orders for the resident to receive 720 milligrams (mg) of Daptomycin (an antibiotic) intravenously (IV) once a day (5:00 a.m.) and 1 gram of Cefepime (an antibiotic) intravenously every 12 hours (8:00 a.m., 8:00 p.m.).
A nursing note, dated May 30, 2025, at 12:28 a.m. revealed the resident was receiving Cefepime and Daptomycin for osteomyelitis (bone infection) of the left heel.
Resident 61's Medication Administration Records (MAR's) for May and June 2025 revealed that the resident received IV Cefepime at 8:00 a.m. May 29 through June 4, 2025; however, there was no documented evidence that staff flushed the resident's midline catheter before and after the administration.
Interview with the Director of Nursing on June 5, 2025, at 11:45 a.m. confirmed that there was no documented evidence that Resident 61's midline was flushed before and after the administration of Cefepime at 8:00 a.m.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending June 27, 2024, and April 22, 2025, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending June 5, 2025, identified repeated deficiencies regarding accuracy of Minimum Data Set (MDS) assessments (mandated assessment of a resident's abilities and care needs), issues with intravenous therapy, and following infection control practices.
The facility's plan of correction for a deficiency regarding a failure to ensure that MDS assessments were accurate upon submission, cited during the survey ending June 27, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to accurate MDS assessments.
The facility's plan of correction for a deficiency regarding a failure to ensure that intravenous therapy was completed correctly, cited during the survey ending on June 27, 2024, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F694, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding intravenous therapy.
The facility's plans of correction for deficiencies regarding infection control practices, cited during the surveys ending June 27, 2024, and April 22, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding infection control practices.
Refer to F641, F694, F880.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
Apr 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized ...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for one of six residents reviewed (Resident 5).
Findings include:
The facility's policy regarding comprehensive care planning, dated August 14, 2024, revealed that the facility will develop a comprehensive person-centered care plan for each resident that includes measurable goals and timetables to meet the resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment.
A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 5, dated March 14, 2025, revealed that the resident was understood, could understand others, had an indwelling catheter (a flexible tube inserted into the bladder to drain urine), had diagnoses that included a wound infection, Multiple Sclerosis (MS - a disease that causes breakdown of the protective covering of nerves), and a Stage 4 pressure ulcer (full-thickness skin and tissue loss, with exposure of muscle, tendon, or bone) of the sacral region (bottom of the spine).
Physician's orders for Resident 5, dated April 5, 2024, included an order for the resident to be on Enhanced Barrier Precautions (infection control measures that involve using gowns and gloves during high-contact resident care activities, in addition to standard precautions).
Observations of Resident 5's room on April 22, 2025, at 10:06 a.m. revealed that there was an Enhanced Barrier Precaution sign outside the resident's room. The sign indicated that staff were to wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use central lines (a long, thin, flexible tubes inserted into a large vein, usually in the chest or neck, and threaded up to a vein near the heart), urinary catheter, feeding tube, tracheostomy (a surgical procedure where an opening (stoma) is made in the neck and into the trachea (windpipe), wound care, and any skin opening requiring a dressing.
However, as of April 22, 2025, there was no documented evidence that a comprehensive care plan that included specific and individualized interventions was developed for Resident 5 regarding her Enhanced Barrier Precautions.
Interview with the Director of Nursing on April 22, 2025, at 3:37 p.m. confirmed that there was no documented evidence that a comprehensive care plan that included specific and individualized interventions was developed for Resident 5 regarding her Enhanced Barrier Precautions.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of manufacturer's directions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide care and treatment in accordance ...
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Based on review of manufacturer's directions and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice, by failing to follow physician's orders for one of six residents reviewed (Resident 2).
Findings include:
Manufacturer's direction for use of diclofenac sodium topical gel 1 percent (a nonsteroidal anti-inflammatory drug (NSAID) used to treat mild-to-moderate pain), undated, revealed: Important: Use the dosing card that is inside the diclofenac sodium topical gel carton to correctly measure each dose. The dosing card is re-usable. Do not throw the dosing card away. For each upper body area (hand, wrist, or elbow), squeeze out 2.25 inches (two grams) and apply. For each lower body area (foot, ankle, or knee), squeeze out 4.5 inches (four grams) and apply.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 7, 2025, revealed that the resident was understood, and could understand others. A care plan for the resident, dated March 3, 2025, revealed that the resident was at risk for pain related to impaired mobility. Staff was to administer medications as per physician's order.
Physician's orders for Resident 2, dated March 17, 2025, included an order for staff to apply four grams of diclofenac sodium topical gel 1 percent to the resident's right knee four times a day.
Observations during the medication administration on April 22, 2025, at 9:25 a.m. revealed that Licensed Practical Nurse 1 entered Resident 2's room and applied gloves, and without using the diclofenac sodium topical gel dosing card she squeezed out an unmeasured amount of the diclofenac sodium topical gel onto her gloved finger, and then applied to the front of the resident's right knee. Then without using the diclofenac sodium topical gel dosing card she squeezed out another unmeasured amount of the diclofenac sodium topical gel onto her gloved finger, and then applied to the back of the resident's right knee.
Interview with Licensed Practical Nurse 1 on April 22, 2025, at 9:41 a.m. confirmed that she did not use the diclofenac sodium topical gel dosing card to measure out the dose of diclofenac sodium topical gel prior to applying it to Resident 2's right knee. She indicated that a dosing card only comes with the prescription strength diclofenac sodium topical gel and not with the over-the-counter strength diclofenac sodium topical gel, which is what they receive from the facility's pharmacy.
Interview with the Director of Nursing on April 22, 2025, at 1:25 p.m. confirmed that Licensed Practical Nurse 1 should have measured the diclofenac sodium topical gel prior to applying it to Resident 2's right knee to ensure the appropriate dose was received as ordered by the physician.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed ...
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Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination, and failed to ensure that proper infection control practices were performed during care for one of six residents reviewed (Resident 5).
Findings include:
CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP's) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP's during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.
The facility's policy regarding transmission-based precautions and isolation, dated August 14, 2024, indicated that EBP's are intended to prevent transmission of MDRO's via contaminated hands and clothing of healthcare workers to high-risk residents. EBP are indicated for high-risk contact care activities for residents with chronic wounds and indwelling devices such as central lines, urinary catheters, and tracheostomies, and for all those colonized or infected with a MDRO currently targeted by the CDC.
A quarterly Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 5, dated March 14, 2025, revealed that the resident was understood, could understand others, had an indwelling catheter (a flexible tube inserted into the bladder to drain urine), had diagnoses that included a wound infection, Multiple Sclerosis (MS - a disease that causes breakdown of the protective covering of nerves), and a Stage 4 pressure ulcer (full-thickness skin and tissue loss, with exposure of muscle, tendon, or bone) of the sacral region (bottom of the spine).
Physician's orders for Resident 5, dated April 5, 2024, included an order for the resident to be on EBPs.
Observations of Resident 5's room on April 22, 2025, at 10:06 a.m. revealed that there was an EBP sign outside the resident's room. The sign indicated that staff were to wear gloves and a gown for the following high contact resident care activities: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting, device care or use central lines (a long, thin, flexible tubes inserted into a large vein, usually in the chest or neck, and threaded up to a vein near the heart), urinary catheter, feeding tube, tracheostomy (a surgical procedure where an opening (stoma) is made in the neck and into the trachea (windpipe), wound care, and any skin opening requiring a dressing. Nurse Aide 2 and Nurse Aide 3 entered the resident's room wearing only gloves. Nurse Aide 3 went to the resident's right side and Nurse Aide 2 went to the resident's left side. Nurse Aide 2 and Nurse Aide 3 then rolled the resident onto her left side. Nurse Aide 3 loosened the resident's brief, and the resident was incontinent of bowel. Nurse Aide 3 then removed the soiled outer dressing to the resident's wounds and then began to provide incontinent care. After she completed providing the incontinent care, she removed the packing from the resident's wounds and placed the soiled dressings in the resident's brief. Without removing her gloves and performing hand hygiene Nurse Aide 3 then obtained the mechanical lift sling and placed it under the resident. Nurse Aide 2 and Nurse Aide 3 then rolled the resident onto her back then rolled her slightly to her right where Nurse Aide 2 then pulled the lift sling under the resident. Nurse Aide 2 and Nurse Aide 3 then returned the resident to her back. Nurse Aide 2 and Nurse Aide 3 then both removed their gloves and used hand gel. Nurse Aide 2 and Nurse Aide 3 reapplied gloves. After getting the resident out of bed Nurse Aide 2 then began to remove the resident's linen from the bed.
Interview with the Director of Nursing on April 22, 2025, at 1:25 p.m. confirmed that Nurse Aide 2 and Nurse Aide 3 should have been wearing gowns in addition to their gloves while providing care to Resident 5 and that Nurse Aide 3 should have removed her gloves and preformed hand hygiene after removing the resident dressings to her wounds and providing incontinent care prior to providing any additional care to the resident.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Dec 2024
2 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse...
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Based on review of facility policies, investigation reports, and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from abuse or neglect for one of four residents reviewed (Resident 2) who was transferred incorrectly, resulting in a fall with a head laceration requiring staples. This deficiency was cited as past noncompliance.
Findings include:
The facility's abuse policy, dated September 11, 2024, indicated that the facility will not tolerate abuse, mistreatment, exploitation of residents, and misappropriation of resident property by anyone.
The facility's policy on mechanical lifts, dated September 11, 2024, indicated that a two-person assist is required for all mechanical lifts, including Hoyer lifts (a mechanical lift that features a U-shaped base, an overhead bar, and a sling that work together to lift, reposition, and lower a patient into a chair or bed).
A quarterly Minimum Data Set (MDS) assessment (required assessments of a resident's abilities and care needs) for Resident 2, dated November 6, 2024, indicated that the resident understood and was understood by others, was cognitively intact, was dependent on staff for daily care needs, and had diagnoses that included quadriplegia (a medical condition where the person has all loss of movement in all arms and legs), and multiple sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord).
A nursing note for Resident 2, dated November 28, 2024, at 8:17 p.m., indicated that the resident was being transferred onto his bed by Nurse Aide 1 by a mechanical lift when the sling pad slipped from under the resident and he hit his head on the headboard resulting in a laceration to the back of his head. The physician was notified and new orders were received to transfer the resident to the emergency room.
A nursing note for Resident 2, dated November 28, 2024, at 9:15 p.m., revealed that the resident returned from the emergency room with three staples to the back of his head.
An incident report for Resident 2, dated December 6, at 12:05 p.m., revealed that the resident was transferred in a Hoyer lift by Nurse Aide 1. The sling pad slipped from under the resident causing him to hit his head on the headboard resulting in a laceration that required three staples.
Nurse Aide 1 received the facility's abuse training on June 4, 2024.
Interview with the Director of Nursing on December 11, 2024, at 10:08 a.m. confirmed that Nurse Aide 1 was aware of the facility's policy for transferring a resident with two persons in a Hoyer lift and should have had a second person assist with the transfer of Resident 2.
A review of the facility's plan of correction included the following:
Reeducation on transporting residents in mechanical lifts and transfers completed for all nursing staff, including nurse aides, licensed practical nurses, and registered nurses.
Audits of residents that require mechanical lifts and assist with transfers.
Audits to be completed three days a week for four weeks to ensure proper transfer status is being used.
Interviews with nursing staff on December 11, 2024, revealed that they had been educated on proper transfers of residents.
A review of the facility's corrective actions revealed that they were in compliance with F600 on December 3, 2024.
Interview with the Director of Nursing on December 11, 2024, revealed that staff education was completed and ongoing audits will be discussed monthly during the Quality Assurance (QA) meeting.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on review of facility policies, investigation documents, and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of f...
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Based on review of facility policies, investigation documents, and clinical records, as well as staff interviews, it was determined that the facility failed to maintain a safe environment for one of four residents reviewed (Resident 2), resulting in an incident that required staples for a laceration on his head. This deficiency was cited as past non-compliance.
Findings include:
The facility's policy on mechanical lifts, dated September 11, 2024, indicated that a two-person assist is required for all mechanical lifts, including Hoyer lifts (a mechanical lift that features a U-shaped base, an overhead bar, and a sling that work together to lift, reposition, and lower a patient into a chair or bed).
A quarterly Minimum Data Set (MDS) assessment (required assessments of a resident's abilities and care needs) for Resident 2, dated November 6, 2024, indicated that the resident understood and was understood by others, was cognitively intact, was dependent on staff for care, including transfers and bed mobility, and had diagnoses that included quadriplegia (a medical condition where the person has all loss of movement in all arms and legs), and multiple sclerosis (a chronic, autoimmune disease that affects the brain and spinal cord). The current care plan for Resident 2 indicated that he was a two-person assist for transfers.
An incident report for Resident 2, dated December 6, at 12:05 pm., revealed that the resident was transferred in a Hoyer lift by Nurse Aide 1, the sling pad slipped from under the resident, and he hit his head on the headboard causing a laceration that required three staples.
Interview with the Director of Nursing on December 11, 2024, at 10:08 a.m. confirmed that two people should have been transferring Resident 2 while using the mechanical lift.
A review of the facility's plan of correction included the following:
Reeducation on transferring residents in mechanical lifts completed for all nursing staff, including nurse aides, licensed practical nurses, and registered nurses.
Audits of residents that require mechanical lifts and assist with transfers.
Audits of transfers will be completed three days a week for four weeks to ensure proper transfer status is being used.
Interviews with nursing staff on December 11, 2024, revealed that they had been educated on proper transfers of residents.
A review of the facility's corrective actions revealed that they were in compliance with F689 on December 3, 2024.
Interview with the Director of Nursing on December 11, 2024, revealed that staff education was completed and ongoing audits will be discussed monthly during the Quality Assurance (QA) meeting.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain the confidentiality of residents' medical information for two of s...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain the confidentiality of residents' medical information for two of seven residents reviewed (Residents 6, 7). The deficiency is being cited as past non-compliance.
Findings include:
The facility's policy regarding privacy, dated January 22, 2024, indicated that the facility could only use and disclose protected health information as permitted or required under HIPAA (Health Insurance Portability and Accountability Act) rules.
A facility investigation, dated September 15, 2024, revealed that Resident 6's health information was provided to Resident 1's family member, who then presented the information to Resident 1's outside physician. Upon return to the facility, the family member again asked for Resident 1's health information and was provided a copy of Resident 7's health information instead.
Interview with the Nursing Home Administrator on October 2, 2024, at 2:58 p.m. confirmed that Resident 6 and 7's health information was provided to Resident 1's family member and should not have been.
Following the identification that the wrong health information was provided, the facility's corrective actions included:
Resident 6 and 7 were notified that their health information was accidentally released.
Audits were completed to ensure that the correct health information was provided for appointments.
Staff were provided a verbal warning for providing the wrong health information and educated on verifying documents prior to handing them to family members/sending information on appointments. All nursing staff were educated on the facility's HIPAA privacy policy.
The Director of Nursing/designee will conduct HIPAA audits three days per week for four weeks, then monthly for two months, to ensure residents who were going to appointments were sent with the appropriate paperwork. The findings would be reviewed with the quality assurance performance improvement committee.
A review of the facility's corrective actions revealed that they were in compliance with F583 on September 16, 2024.
28 Pa. Code 201.29(a) Resident Rights.
28 Pa. Code 211.5(b) Clinical Records.
Jul 2024
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed
to ensure that clinical records were complete and accurately documented for o...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed
to ensure that clinical records were complete and accurately documented for one of four residents reviewed
(Resident 1). This deficiency was cited as past noncompliance.
Findings include:
The facility's policy regarding condom catheters (a urine collection device that fits like a condom over the penis, but also has a tube that goes to a collection bag strapped to the leg), dated August 14, 2023, indicated that condom catheters will be changed daily and as needed.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated May 8, 2024, revealed that the resident was understood, could understand others, had an external catheter, had diagnoses that included Multiple Sclerosis (a chronic disease of the central nervous system), and quadriplegia (a condition where all four limbs experience paralysis). A care plan for the resident, dated April 3, 2024, revealed that the resident required an external catheter related to a neuromuscular dysfunction (affecting the function of muscles due to problems with the nerves and muscles in the body) of his bladder. Staff were to change his condom catheter per the physician's order and as needed.
Physician's orders for Resident 1, dated May 1, 2024, included an order for condom catheter care. Staff were to provide catheter and peri-care (washing the genitals and anal area) that included cleansing around the catheter and the perineal site with soap and water as needed every shift, and staff were to record the urinary output amount every shift.
A nursing note for Resident 1, dated April 1, 2024, revealed that the resident arrived at the facility with his wife and daughter via electric wheelchair, and his wife was steering the electric wheelchair due to resident not being able to use his hands. The resident was alert and oriented and had a condom catheter.
A nursing note for Resident 1, dated July 15, 2024, revealed that the resident was readmitted to the facility from the hospital. The resident's wife was requesting that his condom catheter be replaced daily (she provided them) and the order was updated.
Review of Resident 1's Medication Administration Records (MARs), dated April, May, June, and July 2024, revealed that there was no documented evidence that the resident's condom catheter was being changed daily as per the facility's policy until July 15, 2024, when a physician's order was obtained for staff to change the resident's condom catheter daily per the family request.
Interview with Resident 1 on July 24, 2024, at 11:15 a.m. revealed that staff have been changing his condom catheter daily.
Interview with the Nursing Home Administrator on July 24, 2024, at 4:32 p.m. revealed that when Resident 1's wife requested that his condom catheter be changed daily, they realized that the resident did not have a specific physician's order to change the resident's condom catheter daily. She indicated that staff interviews conducted during their investigation revealed that they were changing the condom catheter when they were doing the resident's cath care. She indicated that they caught it and obtained orders.
Following Resident 1's wife request on July 15, 2024, the facility's corrective actions included:
Interviews were conducted with staff to see if the condom catheter was being changed daily.
A physician's order was obtained to change Resident 1's condom catheter daily, so it would be documented on the MARs.
An audit was performed to see if any other residents had a condom catheter.
Education was provided to licensed nursing staff on following/signing off orders and changing condom catheters per the facility's policy.
Audits will be performed three days per week for four weeks, then monthly for two months.
The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary.
Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F842 on July 17, 2024.
28 Pa. Code 211.5(f) Clinical Records.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Jun 2024
14 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by fai...
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Based on review of facility policy and clinical records, observations, and staff interviews, it was determined that the facility failed to provide reasonable accommodation of a resident's needs by failing to ensure that the call bell was within reach for one of 45 residents reviewed (Resident 8).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 10, 2024, indicated that the resident was understood and could understand, and she required maximum assistance for transfers and toileting. The resident's current care plan indicated that the resident had decreased mobility and that staff were to ensure the call bell was within reach.
A facility policy for call light policy, dated August 14, 2023, revealed that call light will be within easy reach.
Observations of Resident 8 on June 24, 2024, at 11:38 a.m. revealed that the resident was lying in bed, and the call bell was hanging off the back of the bed onto the floor and was not within her reach.
Interview with Licensed Practical Nurse 1 at that time revealed that Resident 8 was capable of using her call bell and it should have been placed within her reach.
Interview with Director of Nursing on June 25, 2024, at 1:11 p.m. confirmed that the call bell should have been within reach of the resident.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's physician was notified in a timely mann...
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Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's physician was notified in a timely manner about a change in condition for one of 45 residents reviewed (Resident 52).
Findings include:
The facility's policy regarding resident medication rights, dated August 14, 2023, revealed that the facility should notify physician of a resident's refusal of medications for more than 24 hours.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated May 7, 2024, indicated that the resident was understood and could understand, was cognitively impaired, was dependent on staff's assistance for care, and was receiving an antidepressant.
Physician's orders for Resident 52, dated June 23, 2023, included an order for 10 mg Lexapro (a medication to treat depression and anxiety) daily.
Electronic Medical Records for Resident 52 for June 2024 revealed that the resident refused medication on June 1, 2, 3, 4, 17, and 18, 2024.
There was no documented evidence to indicate that the physician was notified about Resident 52's refusal of medication on the above dates.
Interview with the Director of Nursing on June 26, 2024, at1 2:01 p.m. confirmed that there was no documented evidence that Resident 52's physician was notified about the refusals of medication and there should have been.
28 Pa. Code 211.12(d)(3) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Min...
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Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 45 residents reviewed (Residents 38, 73).
Findings include:
The RAI User's Manual, dated October 2023, revealed that Section 16100 psychiatric/mood disorder was to be coded for post-traumatic stress disorder if the resident was diagnosed with that any time during the seven-day look-back period.
A quarterly MDS assessment for Resident 38, dated, June 4, 2024, revealed that Section I16100 was coded, indicating that the resident had a diagnosis of post-traumatic stress disorder.
A social service note, dated May 31, 2024, at 6:59 a.m., indicated that the resident never experienced or witnessed a life threatening or traumatic event.
Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on June 27, 2024, at 1:19 p.m. confirmed that section I16100 of Resident 38's quarterly MDS assessment was coded incorrectly and should have been coded to indicate that the resident had a traumatic brain injury during the seven-day assessment period.
The RAI User's Manual, dated October 2023, revealed that Section N0415E1 Anticoagulant (medicines that help prevent blood clots) Medications was to be coded if an anticoagulant medication was taken by the resident at any time during the seven-day look-back period.
Physician's orders for Resident 73, dated May 9, 2024, included an order for the resident to receive 2.5 milligrams (mg) of Warfarin (an anticoagulant) at bedtime on Sunday, Monday, Wednesday, and Friday, and 2 mg of Warfarin at bedtime on Tuesday, Thursday, and Saturdays.
Review of the Medication Administration Record (MAR) for Resident 73, dated May 2024, revealed that staff had administered 2 mg and 2.5 mg of Warfarin to the resident on May 9 through 23, 2024.
A quarterly MDS assessment for Resident 73, dated, May 14, 2024, revealed that Section NO415E1 was not coded, indicating that the resident to did not receive an anticoagulant medication during the seven-day look-back assessment period.
Interview with the Director of Nursing on June 27, 2024, at 1:36 p.m. confirmed that Resident 73 received an anticoagulant medication during the seven-day look-back period and should have been coded for an anticoagulant medication.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an IV (intravenous - in the vein) dressing change was done as p...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that an IV (intravenous - in the vein) dressing change was done as per facility policy for one of 45 residents reviewed (Resident 4).
Findings include:
The facility's policy regarding changing the dressing (a transparent barrier) of midline catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated August 14, 2023, indicated that midline catheter dressings were to be changed weekly and when the integrity of the dressing became compromised (wet, loose or soiled). In addition, the facility policy indicated that staff were to assess the midline insertion site with each medication administration. The catheter insertion site is a potential entry site for bacteria that may cause a catheter-related infection.
A quarterly Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 4, dated May 18, 2024, revealed that the resident was moderately cognitively impaired and had diagnoses that included bilateral stasis (damaged veins) leg ulcers, bacteremia (a blood infection) and dressing changes. Resident 4's care plan, dated June 20, 2024, indicated that staff would monitor the resident for signs of complications from the IV, such as localized infection or dislodgement.
Physician's orders for Resident 4, dated June 20, 2024, included an order for the resident to receive 4.5 grams of Zosyn (an antibiotic) intravenously (IV - directly in a vein) three times a day for bacteremia until July 14, 2024. Resident 4's Medication Administration Record (MAR) for June 20, 2024, through midnight June 27, 2024, revealed that Zosyn was administered every 8 hours as ordered.
Observations on June 24, 2024, at 2:14 p.m.; June 25, 2024, at 12:51 p.m.; and June 26, 2024, at 9:55 a.m. revealed that the midline dressing on Resident 4's right arm was loose and had lost its integrity.
Interview with Licensed Practical Nurse 2 on June 26, 2024, at 12:05 p.m. confirmed that the midline transparent dressing was visibly loose and and should have been changed.
Interview with the Director of Nursing on June 27, 2024, at 2:57 p.m. confirmed that the dressing was changed on Sunday as per order; however, it was not changed when the integrity of the dressing was compromised, and it should have been.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the ph...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that residents received oxygen as ordered by the physician for two of 45 residents reviewed (Residents 8, 70).
Findings include:
The facility's policy regarding oxygen therapy, dated August 14, 2023, indicated that oxygen was to be administered in accordance with physician's orders.
An admission Minimum data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 10, 2024, revealed that the resident was understood and understood others, cognitively intact, had diagnoses that included asthma and respiratory failure, and had shortness of breath related to her current condition.
Physician's orders for Resident 8, dated June 10, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils).
Observations of Resident 8 on June 24, 2024, at 11:44 a.m.; June 25, 2024, at 8:15 a.m.; and June 26, at 1:49 p.m. revealed that the resident was in her room receiving oxygen from an oxygen concentrator (electrical machine that concentrates oxygen from the air) that was set at 4 liters per minute.
Interview with Licensed Practical Nurse 3 on June 26, 2024, at 1:49 p.m. confirmed that Resident 8's oxygen flow rate was set at 4 liters per minute and not 2 liters per minute as ordered by the physician.
Interview with the Director of Nursing on June 26, 2024, at 1:58 p.m. confirmed that Resident 8's oxygen flow rate should be set at 2 liters per minute continuously as per physician order, and it was not.
A quarterly MDS assessment for Resident 70, dated June 21, 2024, revealed that the resident was severely cognitively impaired and had diagnoses that included pneumonitis (inflammation in the lungs) and anxiety and was on hospice. Resident 70's current hospice care plan indicated that she had shortness of breath related to her current condition.
Physician's orders for Resident 70, dated June 21, 2024, included an order for the resident to receive continuous oxygen at a flow rate of 2 liters per minute via nasal cannula (tubes that deliver oxygen into the nostrils).
Observations of Resident 70 on June 24, 2024, at 1:34 p.m.; June 26, 2024, at 1:00 p.m.; and June 27, 2024, at 8:48 a.m. revealed that the resident was in her room receiving oxygen from an oxygen concentrator that was set at 3 liters per minute.
Interview with Licensed Practical Nurse 2 on June 26, 2024, at 12:05 p.m. confirmed that Resident 70's oxygen flow rate was set at 3 liters per minute and not 2 liters per minute as ordered by the physician.
Interview with the Director of Nursing on June 26, 2024, at 12:26 p.m. confirmed that Resident 70's oxygen flow rate should be set at 2 liters per minute continuously as per physician order, and it was not.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that medications remained properly secured in one of four medication carts reviewed (lower level medication cart) and failed to discard expired in-use stock medications.
The facility's policy regarding medication administration, dated [DATE], indicated that the purpose was to provide a method for the safe, accurate administration of oral medications to residents.
Observations of the lower level medication cart on [DATE], at 9:17 a.m. revealed that it was unlocked and unattended. The medication cart was facing room [ROOM NUMBER] while the nurse was administering medications to residents in that room. However, the door was shut to the room, which blocked the nurses direct view of the medication cart.
Observations of the top drawer of the lower level medication cart on [DATE], at 9:29 a.m. revealed an undated/unmarked medication cup that contained one small, round yellow tablet; one small orange tablet; one white oval capsule; and one large oval white tablet.
Observations in the stock drawer of the lower level medication cart on [DATE], at 9:35 a.m. revealed that an opened in-use bottle of Rolaids (medication for an upset stomach) had an expiration date of [DATE].
Interview with Licensed Practical Nurse 2 at that time confirmed that the medication cart was unlocked and not in full view when she was in room [ROOM NUMBER] providing medications, that an undated/unmarked medication cup that contained medications in the top drawer of the medication cart should not have been there, and that the expired bottle of Rolaids should not have been in circulation in the medication cart.
Interview with the Director of Nursing on [DATE], at 9:30 a.m. confirmed that staff should have kept the unlocked medication cart in full line of view while providing resident medications, that an undated/unmarked medication cup that contained medications should not have been in the top drawer of the medication cart, and a bottle of Rolaids that expired in 2021 should not have been in the medication cart.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policies, observations, and staff interviews, it was determined that the facility failed to ensure that food was prepared and served under sanitary conditions, in accordance with professional standards for food service safety.
Findings include:
The facility's policy regarding food and nutrition services, dated August 14, 2023, indicated that employees will wear a clean, appropriate hairnet/hair restraint, and that beards and facial hair will be contained.
Observations in the main kitchen on June 25, 2024, at 1:50 p.m. revealed that Dietary Aide 4 did not have a beard guard covering his beard.
Interview with the Dietary Manager on June 25, 2024, at 1:55 p.m. confirmed that Dietary Aide 4 did not have a beard guard on to cover his beard and should have.
Observations of sanitizer on June 26, 2024, at 1:15 p.m. revealed that the sanitizer level in the three-compartment sink was 500 parts per million (ppm).
A review of the three-compartment sink sanitizer log revealed that the sanitizer level was 500 ppm on February 1, 2024; February 2, 2024; March 3, 2024; March 7, 2024; March 8, 2024; March 12, 2024; March 18, 2024; and March 27-31, 2024.
Manufacturer instructions for [NAME] Sani-Quat no-rinse sanitizer revealed that the sanitizer level must be 200-400 ppm.
Safety Data sheet for [NAME] Sani-Quat no-rinse sanitizer revealed that sanitizer at higher than recommended strength can cause harm.
Interview with Nursing Home Administrator on June 27, 2024, at 8:42 a.m. confirmed that the sanitizer level should be from 200-400 ppm and was not on the above dates.
28 Pa. Code 201.18(e) (2.1) Management.
28 Pa. Code 211.6(f) Dietary Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) surveys ending September 18 and October 25, 2023, and July 27, 2023, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending June 27, 2024, identified repeated deficiencies regarding notification of the physician, quality of care, issues with intravenous therapy, preventing issues with the accountability of controlled medications (drugs with the potential to be abused), ensuring medications were properly stored/labeled, ensuring that food was prepared/stored/served under sanitary conditions, and following infection control practices.
The facility's plan of correction for a deficiency regarding notifying the physician/responsible party about changes in condition, cited during the survey ending September 18, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F580, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding physician/responsible party notification.
The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending July 20 and September 18, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.
The facility's plan of correction for a deficiency regarding a failure ensure that intravenous therapy was completed correctly, cited during the survey ending on July 20, 2023, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F694, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding intravenous therapy.
The facility's plan of correction for a deficiency regarding the failure to account for controlled medications, cited during the survey ending July 20 and September 18, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.
The facility's plans of correction for deficiencies regarding storage and labeling of medications, cited during the survey ending July 20, 2023, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storage and labeling of medications.
The facility's plan of correction for a deficiency regarding appropriate food storage cited during the survey ending October 25, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F812, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding preparing/storing/serving food under sanitary conditions.
The facility's plans of correction for deficiencies regarding infection control practices, cited during the survey ending July 20, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding infection control practices.
Refer to F580, F684, F694, F755, F761, F812, F880.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices and techniq...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices and techniques were followed during the administration of medications.
Findings include:
The facility's policy regarding hand hygiene and medication administration through certain routes, dated August 14, 2024, indicated that staff were to perform hand hygiene prior to administering medications and specifically prior to eye drop administration.
Physician's orders for Resident 15, dated July 6, 2023, included an order for the resident to receive Restasis (medication for dry eyes) one drop in each eye twice a day.
Observations during medication administration on June 26, 2024, at 8:52 a.m. revealed that Licensed Practical Nurse 2 prepared Resident 15's medications and without performing hand hygiene she administered the resident her po (by mouth) medications. Then without performing hand hygiene once again, she administered the resident her eye drops.
Interview with Licensed Practical Nurse 2 on June 26, 2024, at that time confirmed that she should have performed hand hygiene prior to administering Resident 15's medications and again before administering the resident her eye drops.
Interview with the Director of Nursing on June 27, 2024, at 9:30 a.m. confirmed that Licensed Practical Nurse 2 should have performed hand hygiene prior to administering the resident's medications and again before administering the resident her eye drops.
28 Pa. Code 211.12(d)(1) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and leg...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for seven of 45 residents reviewed (Residents 6, 7, 53, 58, 72, 73, 86).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated April 17, 2024, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had diagnoses that included diabetes.
A nursing note for Resident 6, dated August 6, 2024, at 8:26 p.m., revealed that the resident was sent to the hospital per his request because he felt something was wrong.
There was no documented evidence that a written notice of Resident 6's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.
A quarterly MDS assessment for Resident 7, dated May 29, 2024, indicated that the resident was cognitively intact, required assistance with his daily care needs, and had diagnoses that included myocardial infarction (blockage that prevents oxygen-rich blood from getting to the heart).
A nursing note for Resident 7, dated November 26, 2023, at 5:03 p.m., revealed that the resident had complained of increased shortness of breath and was requesting to go to the hospital. The physician was notified, and the resident was transferred to the emergency room for evaluation.
There was no documented evidence that a written notice of Resident 7's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.
A quarterly MDS assessment for Resident 53, dated May 30, 2024, indicated that the resident was cognitively intact, required assistance from staff for his daily care needs, had pressure sores, and had diagnoses that included a right ankle fracture.
A nursing note for Resident 53, dated May 20, 2024, at 4:23 p.m. revealed that a large area was found under his cast that needed debrided (removal of dead, damaged, or infected tissue) and he was sent to the hospital. A nursing note, dated May 22, 2024, at 7:01 a.m., revealed that the resident was admitted to the hospital and the bed hold policy was sent out.
There was no documented evidence that a written notice of Resident 53's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.
A quarterly MDS assessment for Resident 58, dated April 24, 2024, indicated that the resident was understood and able to understand others, required set-up or clean-up assistance with personal hygiene care, and had diagnoses that included dementia.
A nursing note for Resident 58, dated November 26, 2023, at 5:03 p.m., revealed that the resident had a change in condition that included shortness of breath and increased confusion. The physician was notified, and the resident was transferred to the emergency room for evaluation.
There was no documented evidence that a written notice of Resident 58's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.
A quarterly MDS assessment for Resident 72, indicated that the resident was understood and able to understand others, required assistance from staff for his daily care needs, and had diagnoses that included chronic obstructive pulmonary disease (COPD- lung disease causing restricted air flow and breathing problems).
A nursing note for Resident 72, dated May 5, 2024, at 11:52 a.m., revealed that the resident was observed to be unresponsive and cyanotic. The physician was notified, and the resident was transferred to the emergency room for evaluation.
There was no documented evidence that a written notice of Resident 72's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.
A quarterly MDS assessment for Resident 73, dated May 14, 2024, indicated that the resident could make himself understood and understands others, required assistance from staff for his daily care needs, had pressure ulcers, and had an infection of his foot.
A nursing note for Resident 73, dated November 23, 2023, at 5:10 a.m., revealed that the resident had an unstageable diabetic pressure ulcer on his left heel that measured 4.0 x 5.0 centimeters (cm). A nursing note, dated April 25, 2024, at 9:09 p.m., revealed that the wound team indicated that his wound was much larger in size and was showing signs of infection. He was transferred to the hospital and admitted with weakness, a urinary tract infection, and osteomyelitis (bone infection).
There was no documented evidence that a written notice of Resident 73's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.
Review of census records for Resident 86 revealed that the resident was admitted to the facility on [DATE].
A nursing note for Resident 86, dated March 27, 2024, at 10:54 a.m., revealed that the certified registered nurse practitioner (a registered nurse who has advanced clinical education and training) requested that the resident be transferred to the emergency room for evaluation related to abnormal labs and renal failure.
There was no documented evidence that a written notice of Resident 86's transfer to the hospital was provided to the resident's responsible party regarding the reason for transfer.
Interview with the Nursing Home Administrator on June 27, 2024, at 3:13 p.m. confirmed that the facility did not provide a written notice to the resident or the resident's responsible party when a resident was transferred to the hospital.
28 Pa. Code 201.25 Discharge Policy.
28 Pa. Code 201.29(f)(g) Resident Rights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission and annual Minimum Data Set assessments were completed in the required time frame for five of 45 residents reviewed (Residents 12, 53, 65, 69, 77). The deficiency was cited as past non-compliance
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that an admission MDS assessment was to be completed no later than 14 days following admission, that the Assessment Reference Date (ARD - the last day of an assessment's look-back period) must be set within 366 days after the ARD of the previous comprehensive assessment, and that the assessment was to be completed no later than the ARD plus 14 calendar days.
An admission MDS assessment for Resident 12 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on March 22, 2024, which was 17 days after admission.
An admission MDS assessment for Resident 53 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on April 3, 2024, which was 21 days after admission.
An admission MDS assessment for Resident 65 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on March 25, 2024, which was 19 days after admission.
An admission MDS assessment for Resident 69 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on December 29, 2023, which was 14 days after admission.
An admission MDS assessment for Resident 77 revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on April 1, 2024, which was 20 days after admission.
An interview with Nursing Home Administrator on June 27, 2024, at 10:08 a.m. confirmed that Residents 12, 53, 65, 69, and 77's comprehensive MDS assessments were completed late.
Following identification that MDS information was completed late, the facility's corrective actions included:
The MDS assessments cited cannot be resubmitted to the Centers for Medicare and Medicaid Services to correct the late completions.
The scheduled MDS assessments within the previous 14 days were reviewed to ensure timely completion.
The clinical reimbursement specialist educated the MDS coordinators, and the Nursing Home Administrator educated the interdisciplinary team members on the timing requirements for completion of MDS assessments.
The Nursing Home Administrator completed audits of MDS submissions twice weekly for two weeks. Audits will continue twice weekly for a total of four weeks then monthly for two months to ensure timely completion. The findings will be reviewed with the quality assurance performance improvement committee for additional recommendations.
A review of the facility's corrective actions revealed that they were in compliance with F636 on June 19, 2024.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected multiple residents
Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set ass...
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Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required timeframe for five of 65 residents reviewed (Residents 2, 17, 47, 59, 72). The deficiency is being cited as past non-compliance.
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to be completed no later than the ARD plus 14 calendar days.
A quarterly MDS assessment for Resident 2, with an ARD of March 13, 2024, was due to be completed by March 27, 2024, but was not signed as completed until March 28, 2024, which was 15 days from the ARD until completion.
A quarterly MDS assessment for Resident 17, with an ARD of March 7, 2024, was due to be completed by March 21, 2024, but was not signed as completed until March 22, 2024, which was 15 days from the ARD until completion.
A quarterly MDS assessment for Resident 47, with an ARD of March 12, 2024, was due to be completed by March 26, 2024, but was not signed as completed until March 27, 2024, which was 15 days from the ARD until completion.
A quarterly MDS assessment for Resident 59, with an ARD of March 13, 2024, was due to be completed by March 27, 2024, but was not signed as completed until March 28, 2024, which was 15 days from the ARD until completion.
A quarterly MDS assessment for Resident 72, with an ARD of March 12, 2024, was due to be completed by March 26, 2024, but was not signed as completed until March 27, 2024, which was 15 days from the ARD until completion.
An interview with Nursing Home Administrator on June 27, 2024, at 10:08 a.m. confirmed that Resident 2's, 17's, 47's, 59's and 72's quarterly MDS assessments were completed late.
Following identification that MDS information was completed late, the facility's corrective actions included:
The MDS assessments cited cannot be resubmitted to the Centers for Medicare and Medicaid Services to correct the late completions.
The scheduled MDS assessments within the previous 14 days were reviewed to ensure timely completion.
The clinical reimbursement specialist educated the MDS coordinators, and the Nursing Home Administrator educated the interdisciplinary team members on the timing requirements for completion of MDS assessments.
The Nursing Home Administrator completed audits of MDS submissions twice weekly for two weeks. Audits will continue twice weekly for a total of four weeks then monthly for two months to ensure timely completion. The findings will be reviewed with the quality assurance performance improvement committee for additional recommendations.
A review of the facility's corrective actions revealed that they were in compliance with F638 on June 19, 2024.
28 Pa. Code 211.5(f) Clinical Records.
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 a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for four of 45 residents reviewed (Res...
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Based on a review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for four of 45 residents reviewed (Residents 17, 37, 40, 46)
Findings include:
The facility's policy regarding medication administration, dated August 14, 2023, indicated that during medication administration, facility staff should take all measures required by facility policy and applicable law, document the administration of controlled substances in accordance with applicable law and observe the resident's consumption of the medication(s), and document necessary medication administration/treatment information on appropriate forms.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated May 22, 2024, revealed that the resident was understood, could understand others, was cognitively impaired, and was independent for care.
Physician's orders for Resident 17, dated May 8, 2024, included orders for the resident to have full head-to-toe assessment with vital signs to be completed every shift along with nurse's notes.
A nurse's note for May 10, 2024, at 4:10 a.m. revealed that a full head-to-toe assessment including vital signs was completed for Resident 17.
A review of the health record for Resident 17 revealed no documented evidence that a full head-to-toe assessment was complete, except on May 10, 2024, at 4:10 a.m.
Interview with the Director of Nursing on June 26, 2024, at 1:26 p.m. confirmed that the physician ordered a full head-to-toe assessment for Resident 17 to be competed per shift, and the only documented evidence that it was completed was on May 10, 2024, at 4:10 a.m.
A quarterly MDS assessment for Resident 37, dated April 16, 2024, revealed that the resident was moderately cognitively impaired, received insulin, and had diagnoses that included diabetes. Physician's orders, dated February 18, 2024, included an order for the resident to receive 12 units of Insulin Lispro (insulin) and to hold the insulin if the blood sugar was less than 80 milligrams/deciliter (mg/dL). A care plan, dated April 2, 2024, indicated that staff were to administer medications as ordered by the physician.
Review of Resident 37's Medication Administration Record (MAR), dated April, May and June 2024, revealed that at 7:00 a.m. on April 25, 2024, the resident's blood sugar was 88 mg/dL; on May 14, 2024, the resident's blood sugar was 85 mg/dL; on May 24, 2024, the resident's blood sugar was 89 mg/dL; on May 25, 2024, the resident's blood sugar was 82 mg/dL; on May 26, 2024, the resident's blood sugar was 93 mg/dL; on June 2, 2024, the resident's blood sugar was 84 mg/dL; on June 8, 2024, the resident's blood sugar was 101 mg/dL; and on June 16, 2024, the resident's blood sugar was 87 mg/dL. However, the resident's insulin was held on the dates listed.
Interview with the Director of Nursing on June 27, 2024, at 9:19 a.m. confirmed that Resident 37's insulin should not have been held according to the ordered parameters on the mentioned dates and times.
An annual MDS assessment for Resident 40, dated May 14, 2024, revealed that the resident was cognitively intact, was frequently incontinent of urine, and received an antibiotic.
A nursing note, dated May 16, 2024, at 11:06 a.m. revealed that the Certified Registered Nurse Practitioner (CRNP) was in and reviewed the results of the urinalysis (urine test) and culture and sensitivity results (C&S - urine test that identifies specific bacteria and which antibiotics should be used to treat the infection), and a new order was received for 500 mg of Cipro (antibiotic) twice a day for 10 days.
Review of Resident 40's MAR, dated May 2024, revealed that the resident received 500 mg of Cipro twice a day from May 17 through May 27, 2024 (11 days).
Interview with the Director of Nursing on June 27, 2024, at 3:13 p.m. confirmed that Resident 40 received two additional doses of Cipro on May 27, 2024.
A quarterly MDS assessment for Resident 46, dated June 18, 2024, indicated that the resident was cognitively impaired, required assistance with her personal care needs, and had diagnoses that included dementia and hypertension (high blood pressure).
Physician's orders for Resident 46, dated February 17, 2024, included an order for the resident to receive 25 milligrams (mg) of metoprolol tartrate once a day, to be held if the resident's systolic blood pressure (SBP- top number in a blood pressure reading, measures the pressure in the arteries when the heart beats) was less than 100 millimeters of Mercury (mmHg).
Review of the MAR for Resident 46 dated February through June 2024, revealed that on February 19, 2024, the resident's SBP was 81 mmHg; on February 20, 2024, the resident's SBP was 96 mmHg; on March 20, 2024, the resident's SBP was 95 mmHg; on March 26, 2024, the resident's SBP was 85 mmHg; on April 14, 2024, the resident's SBP was 94 mmHg; on May 8, 2024, the resident's SBP was 96 mmHg; on May 26, 2024, the resident's SBP was 98 mmHg; on June 8, 2024, the resident's SBP was 98 mmHg; on June 15, 2024, the resident's SBP was 94 mmHg, and on June 19, 2024, the resident's SBP was 98 mmHg. Documentation on the MAR revealed that 25 mg of metoprolol tartrate was administered on these dates when it should have been held.
Interview with the Director of Nursing on June 27, 2024, at 9:15 a.m. confirmed that the documentation indicates that Resident 46 was administered metoprolol tartrate on the above-mentioned dates and times when it should not have been administered.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potentia...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for two of 45 residents reviewed (Residents 24, 55).
Findings include:
The facility's policy regarding medication administration, dated August 14, 2023, indicated that during medication administration, facility staff should take all measures required by facility policy and applicable law, document the administration of controlled substances in accordance with applicable law, observe the resident's consumption of the medication(s), and document necessary medication administration/treatment information on appropriate forms.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated May 16, 2024, revealed that the resident was cognitively intact, had pain frequently, received pain medication routinely and as needed, and received an opioid (a controlled pain medication).
Physician's orders for Resident 24, dated March 25 and May 10, 2024, included an order for the resident to receive one 10 milligram (mg) tablet of oxycodone (narcotic pain reliever) every four hours as needed for moderate to severe pain.
Resident 24's controlled drug record (a form that accounts for each dose of a controlled drug) for May and June 2024 indicated that one dose of oxycodone was signed out for administration to the resident on May 3 at 4:30 p.m.; May 4 at 5:41 p.m.; May 17 at 6:04 p.m.; May 20 at 3:00 p.m.; May 26 at 9:16 a.m.; June 3 at 9:44 p.m.; June 17 at 9:37 p.m. However, the resident's clinical record, including the MARs and nursing notes, contained no documented evidence that the signed-out dose of oxycodone was actually administered to the resident on these dates and times.
Interview with the Director of Nursing on June 27, 2024, at 1:36 p.m. confirmed that there was no documented evidence that staff administered the signed-out dose of oxycodone to Resident 24 on the above date and time.
A quarterly MDS assessment for Resident 55, dated May 19, 2024, revealed that the resident was cognitively impaired, had pain frequently, received pain medication routinely and as needed, and received a benzodiazepine (a controlled anxiety and antiseizure medication).
Physician's orders for Resident 55, dated April 18, 2024, included an order for the resident to receive 5 milligrams (mg) of diazepam, 5mg/mL (antianxiety medication) daily to wrist and apply 5 mg to wrist every hour as needed for anxiety.
Resident 55's controlled drug record for May 2024 indicated that one dose of diazepam was signed out for administration to the resident on May 8, 2024, at 8:30 p.m. and May 16, 2024, at 2:30 p.m. However, the resident's clinical record, including MARs and nursing notes, contained no documented evidence that the signed-out dose of diazepam was administered to the resident on the above dates and times.
Interview with the Director of Nursing on June 27, 2024, at 4:16 p.m. confirmed that there was no documented evidence that staff administered the signed-out dose of diazepam to Resident 55 on the above dates and times.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Oct 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on review of facility policies, resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.
Findings Inclu...
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Based on review of facility policies, resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.
Findings Include:
The facility's policy regarding food temperatures, dated, August 14, 2023, revealed that all hot items may not fall below 135 Fahrenheit (F) while holding after cooking. Hot foot should be at least 135 degrees F when plated and be palatable at point of delivery.
Observations of the lunch meal service on October 25, 2023, revealed that the fourth and last cart containing a test tray left the kitchen at 11:24 a.m. and arrived on the short hall at 11:26 a.m. Trays were passed to the residents in the dining area across from the nurses' station at 11:26 a.m. Trays were passed to the residents in their rooms at 11:26 a.m. and the last resident was served at 11:30 a.m. The test tray was removed from the cart at 11:31 a.m. and the temperature of the coffee was 135 degrees F, the pork ribs were 133 degrees F, and the potato cubes were 105 degrees F. The coffee and potatoes were lukewarm and not appetizing to taste.
Interview with the Dietary Manager at the time of the observations confirmed that the potatoes were not good.
Interview with Nursing Home Administrator on October 25, 2023, at 2:20 p.m. confirmed that food should be at 135 degrees F and be palatable.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 211.6(c) Dietary services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to distribute and serve food in accordance with professional standards fo...
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Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to distribute and serve food in accordance with professional standards for food service safety by failing to ensure that dietary staff wore gloves on their hands with long false fingernails while serving food.
Findings include:
The facility's policy regarding dress and personal hygiene, dated August 14, 2023, indicated that fingernails should be clean and trimmed. Polished or false nails are not allowed in the food service area unless gloves are worn.
Observations in the kitchen on October 25, 2023, at 10:45 a.m. during the lunch meal revealed that Dietary Aide 1 was plating food items, had false fingernails that were longer than one inch, and she was not wearing gloves.
Interview with the Dietary Manager on October 25, 2023, at 12:09 p.m. confirmed that the dietary aide should have worn gloves while serving food and that her nails should have been trimmed.
28 Pa. Code 211.6(f) Dietary services.
Sept 2023
3 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified timely about the unavailability of a medication f...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the resident's physician was notified timely about the unavailability of a medication for three of five residents reviewed (Residents 2, 3, 5). This deficiency was cited as past non-compliance.
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, required extensive assistance from staff for his daily care tasks, and had a diagnosis which included diabetes, high blood pressure, GERD (gastro-esophageal reflux disease), hyperlipidemia (high lipids), and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly).
Physician's orders for Resident 2, dated June 29, 2023, included orders for the resident to receive 10 milligrams (mg) of aripiprazole (antipsychotic) once a day, 200 micrograms (mcg) aerosol inhaler of Asmanex (used to treat breathing problems) two puffs twice a day, 20 mg of atorvastatin (used to lower cholesterol and triglycerides) at bedtime, 0.2 mg of clonidine HCl (used to treat high blood pressure) twice a day, 180 mg of diltiazem HCl (used to treat high blood pressure) once a day, 20 mg of famotidine (used to prevent heart burn) once a day, 25 mg of hydralazine (used to treat high blood pressure) four times a day, 8 units of insulin glargine (used to treat diabetes) twice a day, 50 mg of metoprolol (used to treat high blood pressure) twice a day, 90 mcg of Pulmicort flexhaler (used to treat breathing problems) one puff twice a day, and 15 mg of Xarelto (blood thinner) daily.
Review of the Medication Administration Records (MAR) for Resident 2, dated July 2023, revealed no documented evidence that the resident was administered aripiprazole at 9:00 a.m. on July 11 and 14; Asmanex the morning on July 11; atorvastatin at bedtime on July 10; clonidine the morning of July 11 and 14 and the evening of July 10; diltiazem daily on July 11; hydralazine at 8:00 a.m. on July 11 and 12, at 12:00 p.m. on July 11, at 4:00 p.m. on July 11 and 12, and at 8:00 p.m. on July 10 and 11; insulin glargine the evening of July 10; and Pulmicort the evening of July 10. There was no documented evidence that the physician was notified that the medications were not available or administered on theses dates and times.
An annual MDS assessment for Resident 3, dated August 12, 2023, revealed that the resident was cognitively impaired, required supervision to limited assistance from staff for her daily care tasks, and had a diagnosis which included high blood pressure, depression, and dementia.
Physician's orders for Resident 3, dated June 21, 2023, included orders for the resident to receive 50 mg of losartan (used to treat high blood pressure) once a day, 5 mg of nebivolol (used to treat high blood pressure) once a day, 20 mg of paroxetine HCl (used to treat depression) once a day, and 20 milliequivalents (mEq) of potassium chloride once day.
Review of the MAR's for Resident 3, dated July 2023, revealed no documented evidence that the resident was administered losartan daily on July 9, 15, 16, and 25; nebivolol daily on July 8, 9, 10, 11, 12, 15, 16, 22, 23, and 25; paroxetine daily on July 9, 10, 22, 23, and 25; and potassium chloride daily on July 8, 9, 10, 11, 12, 15, 16, 22, 23 and 25, 2023. There was no documented evidence that the physician was notified that the medications were not available or administered on theses dates and times.
An annual MDS assessment for Resident 5, dated August 12, 2023, revealed that the resident was cognitively impaired, required supervision to limited assistance from staff for her daily care tasks, and had a diagnosis which included high blood pressure, depression, and dementia.
A nursing note, dated July 7, 2023, at 6:49 p.m. revealed that the resident's urinalysis was reviewed by the Certified Registered Nurse Practitioner and new orders were received for 150 mg of Diflucan (used to treat a fungal infection) now and then give 150 mg of Diflucan in three days.
Review of the MAR's for Resident 5, dated July 2023, revealed that Diflucan was not administered on July 7 or 8, 2023, as ordered. There was no documented evidence that the physician was notified that the Diflucan was not available or administered on July 7 or 8, 2023.
Interview with the Nursing Home Administrator on September 18, 2023, at 4:10 p.m. confirmed that there was no documented evidence that the physician was notified that Resident 2, 3, and 5's medication were not available or administered as ordered on the mentioned dates and times.
Following the facility's identified concern of adjusting to the new over-the-counter medication supplies, the new pharmacy, and new charting system on July 1, 2023, the facility's corrective actions included:
The pharmacy is supplying over-the-counter medications, medication carts were re-organized, central supply has been following up with nursing for appropriate ordering, new resident orders are now faxed directly to the pharmacy, medication times were adjusted to be compliant with the medication pass, and nursing staff was instructed to notify the physician of any medications that were not available from the pharmacy.
Education was provided on August 10 and 29, 2023, with facility care staff regarding looking for medications in the cart, re-ordering medications five to seven days prior to medications running out from the new system, and that compliance reports would be pulled three times a day.
The results of the audits were to be discussed during the QA meetings. The date of compliance was August 29, 2023, and the facility has ongoing audits to monitor compliance.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of f...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for three of five residents reviewed (Residents 2, 3, 5). This deficiency was cited as past non-compliance.
Findings include:
The facility's policy regarding medication administration, dated May 12, 2023, indicated that the facility would ensure that authorized personnel, as determined by applicable law, administer medications according to times of administration as determined by the facility's pharmacy committee and/or physician/prescriber.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, required extensive assistance from staff for his daily care tasks, and had a diagnosis which included diabetes, high blood pressure, GERD (gastro-esophageal reflux disease), hyperlipidemia (high lipids), and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly).
Physician's orders for Resident 2, dated June 29, 2023, included orders for the resident to receive 10 milligrams (mg) of aripiprazole (antipsychotic) once a day, 200 micrograms (mcg) aerosol inhaler of Asmanex (used to treat breathing problems) two puffs twice a day, 20 mg of atorvastatin (used to lower cholesterol and triglycerides) at bedtime, 0.2 mg of clonidine HCl (used to treat high blood pressure) twice a day, 180 mg of diltiazem HCl (used to treat high blood pressure) once a day, 20 mg of famotidine (used to prevent heart burn) once a day, 25 mg of hydralazine (used to treat high blood pressure) four times a day, 8 units of insulin glargine (used to treat diabetes) twice a day, 50 mg of metoprolol (used to treat high blood pressure) twice a day, 90 mcg of Pulmicort flexhaler (used to treat breathing problems) one puff twice a day, and 15 mg of Xarelto (blood thinner) daily.
Review of the Medication Administration Records (MAR) for Resident 2, dated July 2023, revealed no documented evidence that the resident was administered aripiprazole at 9:00 a.m. on July 11, 13, and 14; Asmanex the morning on July 11 and the morning and evening on July 13; atorvastatin at bedtime on July 10, 11 and 13; clonidine the morning of July 11, 13, and 14 and the eveing of July 10; diltiazem daily on July 11 and 13; famotidine daily on July 13; hydralazine at 8:00 a.m. on July 11 and 12, at 12:00 p.m. on July 11 and 13, at 4:00 p.m. on July 11, 12 and 13, and at 8:00 p.m. on July 10, 11 and 13; insulin glargine the evening of July 10 and 13; Pulmicort the evening of July 10, 13 and 14; and Xarelto daily on July 13, 2023.
An annual MDS assessment for Resident 3, dated August 12, 2023, revealed that the resident was cognitively impaired, required supervision to limited assistance from staff for her daily care tasks, and had a diagnosis which included high blood pressure, depression, and dementia.
Physician's orders for Resident 3, dated June 21, 2023, included orders for the resident to receive 50 mg of losartan (used to treat high blood pressure) once a day, 5 mg of nebivolol (used to treat high blood pressure) once a day, 20 mg of paroxetine HCl (used to treat depression) once a day, and 20 milliequivalents (mEq) of potassium chloride once day.
Review of the MAR's for Resident 3, dated July 2023, revealed no documented evidence that the resident was administered losartan daily on July 9, 13, 15, 16, 24, and 25; nebivolol daily on July 8, 9, 10, 11, 12, 13, 15, 16, 22, 23, 24, and 25; paroxetine daily on July 8, 9, 10, 22, 23, 24 and 25; and potassium chloride daily on July 8, 9, 10, 11, 12, 13, 15, 16, 22, 23, and 25, 2023.
An annual MDS assessment for Resident 5, dated August 12, 2023, revealed that the resident was cognitively impaired, required supervision to limited assistance from staff for her daily care tasks, and had a diagnosis which included high blood pressure, depression, and dementia.
A nursing note, dated July 7, 2023, at 6:49 p.m. revealed that the resident's urinalysis was reviewed by the Certified Registered Nurse Practitioner and new orders were received for 150 mg of Diflucan (used to treat a fungal infection) now and then give 150 mg of Diflucan in three days.
Review of the MAR's for Resident 5, dated July 2023, revealed that Diflucan was not administered on July 7 or 8, 2023, as ordered.
Interview with the Nursing Home Administrator on September 18, 2023, at 4:10 p.m. confirmed that Residents 2, 3, and 5 did not receive their medications as ordered.
Following the facility's identified concern of adjusting to the new over-the-counter medication supplies, the new pharmacy, and new charting system on July 1, 2023, the facility's corrective actions included:
The pharmacy is supplying over-the-counter medications, medication carts were re-organized, central supply has been following up with nursing for appropriate ordering, new resident orders are now faxed directly to the pharmacy, medication times were adjusted to be compliant with the medication pass, and nursing staff was instructed to notify the physician of any medications that were not available from the pharmacy.
Education was provided on August 10 and 29, 2023, with facility care staff regarding looking for medications in the cart, re-ordering medications five to seven days prior to medications running out from the new system, and that compliance reports would be pulled three times a day.
The results of the audits were to be discussed during the QA meetings. The date of compliance was August 29, 2023, and the facility has ongoing audits to monitor compliance.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medication was obtained and provided as ordere...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that medication was obtained and provided as ordered by the physician for three of five residents reviewed (Residents 2, 3, 5). This deficiency was cited as past non-compliance.
Findings include:
The facility's policy regarding medication administration, dated May 12, 2023, indicated that the facility would ensure that authorized personnel, as determined by applicable law, administer medications according to times of administration as determined by the facility's pharmacy committee and/or physician/ prescriber.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated July 17, 2023, revealed that the resident was cognitively intact, required extensive assistance from staff for his daily care tasks, and had a diagnosis which included diabetes, high blood pressure, GERD (gastro-esophageal reflux disease), hyperlipidemia (high lipids), and schizophrenia (disorder that affects a person's ability to think, feel, and behave clearly).
Physician's orders for Resident 2, dated June 29, 2023, included orders for the resident to receive 10 milligrams (mg) of aripiprazole (antipsychotic) once a day, 200 micrograms (mcg) aerosol inhaler of Asmanex (used to treat breathing problems) two puffs twice a day, 20 mg of atorvastatin (used to lower cholesterol and triglycerides) at bedtime, 0.2 mg of clonidine HCl (used to treat high blood pressure) twice a day, 180 mg of diltiazem HCl (used to treat high blood pressure) once a day, 20 mg of famotidine (used to prevent heart burn) once a day, 25 mg of hydralazine (used to treat high blood pressure) four times a day, 8 units of insulin glargine (used to treat diabetes) twice a day, 50 mg of metoprolol (used to treat high blood pressure) twice a day, 90 mcg of Pulmicort flexhaler (used to treat breathing problems) one puff twice a day, and 15 mg of Xarelto (blood thinner) daily.
Review of the Medication Administration Records (MAR) for Resident 2, dated July 2023, revealed no documented evidence that the resident was administered aripiprazole at 9:00 a.m. on July 11 and 14; Asmanex the morning on July 11; atorvastatin at bedtime on July 10; clonidine the morning of July 11 and 14 and the evening of July 10; diltiazem daily on July 11; hydralazine at 8:00 a.m. on July 11 and 12, at 12:00 p.m. on July 11, at 4:00 p.m. on July 11 and 12, and at 8:00 p.m. on July 10 and 11; insulin glargine the evening of July 10; and Pulmicort the evening of July 10. The MAR indicated that the medications were unavailable.
An annual MDS assessment for Resident 3, dated August 12, 2023, revealed that the resident was cognitively impaired, required supervision to limited assistance from staff for her daily care tasks, and had a diagnosis which included high blood pressure, depression, and dementia.
Physician's orders for Resident 3, dated June 21, 2023, included orders for the resident to receive 50 mg of losartan (used to treat high blood pressure) once a day, 5 mg of nebivolol (used to treat high blood pressure) once a day, 20 mg of paroxetine HCl (used to treat depression) once a day, and 20 milliequivalents (mEq) of potassium chloride once day.
Review of the MAR's for Resident 3, dated July 2023, revealed no documented evidence that the resident was administered losartan daily on July 9, 15, 16, and 25; nebivolol daily on July 8, 9, 10, 11, 12, 15, 16, 22, 23, and 25; paroxetine daily on July 9, 10, 22, 23, and 25; and potassium chloride daily on July 8, 9, 10, 11, 12, 15, 16, 22, 23 and 25, 2023. There was no documented evidence that the physician was notified that the medications were not available or administered on theses dates and times. The MAR indicated that the medications were unavailable, awaiting pharmacy, or waiting for medications to be delivered by pharmacy.
An annual MDS assessment for Resident 5, dated August 12, 2023, revealed that the resident was cognitively impaired, required supervision to limited assistance from staff for her daily care tasks, and had a diagnosis which included high blood pressure, depression, and dementia.
A nursing note, dated July 7, 2023, at 6:49 p.m. revealed that the resident's urinalysis was reviewed by the Certified Registered Nurse Practitioner and new orders were received for 150 mg of Diflucan (used to treat a fungal infection) now and then give 150 mg of Diflucan in three days.
Review of the MAR's for Resident 5, dated July 2023, revealed that Diflucan was not administered on July 7 or 8, 2023, as ordered. There was no documented evidence that the physician was notified that the Diflucan was not available or administered on July 7 or 8, 2023. The MAR indicated that they were awaiting pharmacy delivery.
Interview with the Nursing Home Administrator on September 18, 2023, at 4:10 p.m. confirmed that the medications for Resident 2, 3, and 5's we not available for administration as ordered on the mentioned dates and times.
Following the facility's identified concern of adjusting to the new over-the-counter medication supplies, the new pharmacy, and new charting system on July 1, 2023, the facility's corrective actions included:
The pharmacy is supplying over-the-counter medications, medication carts were re-organized, central supply has been following up with nursing for appropriate ordering, new resident orders are now faxed directly to the pharmacy, medication times were adjusted to be compliant with the medication pass, and nursing staff was instructed to notify the physician of any medications that were not available from the pharmacy.
Education was provided on August 10 and 29, 2023, with facility care staff regarding looking for medications in the cart, re-ordering medications five to seven days prior to medications running out from the new system, and that compliance reports would be pulled three times a day.
The results of the audits were to be discussed during the QA meetings. The date of compliance was August 29, 2023, and the facility has ongoing audits to monitor compliance.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Jul 2023
12 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that resid...
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Based on review of facility policies, investigation reports, clinical records, and staff education records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from neglect for one of 32 residents reviewed (Resident 14), resulting in harm to Resident 14 due to an improper transfer that resulted in fractures. This deficiency was cited as past non-compliance.
Findings include:
The facility's policy regarding abuse and neglect, dated May 12, 2023, indicated that each resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation. No resident in the facility would be physically, verbally or sexually abused, neglected, have their property misappropriated, suffer from corporal punishment or involuntary seclusion, or be exploited by anyone. Anyone was defined as, but limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies, family members, friends, legal guardians, visitors, or any other individual.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated June 8, 2023, revealed that the resident was cognitively impaired, was dependent on two staff members for transfers, did not ambulate (walk), and had diagnoses that included dementia. The resident's care plan, dated July 20, 2022, revealed that she required a mechanical lift for transfers. An annual therapy screen, dated December 1, 2022, indicated that the resident unable to bear weight and required a mechanical lift for transfers.
A nursing note for Resident 14, dated July 6, 2023, at 9:25 a.m. revealed that the resident complained of pain in the left shoulder. The Certified Registered Nurse Practitioner (CRNP) was notified and orders were received to x-ray the left shoulder.
A CRNP note, dated July 6, 2023, revealed that the resident was seen for complaints of pain to her left shoulder that she was refusing to move. She was also seen for her right knee, which was with purple discoloration, deformity and tenderness. Upon examination the resident had tenderness to her left shoulder and swelling of the right knee with severe pain with any movement. The plan was to x-ray the right hip, femur, knee, leg and ankle regarding pain and deformity.
An x-ray report, dated July 6, 2023, revealed that the resident's left shoulder had a fracture of the surgical neck (the upper arm bone (humerus) closest to the shoulder area) and greater tuberosity (bump of bone at the top of the humerus). An x-ray report, dated July 7, 2023, revealed that the resident had a proximal tibia neck fracture (upper area of the shin bone closest to the knee).
The facility's investigation, dated July 6, 2023, revealed that the daylight nurse aide reported on July 6, 2023, that Resident 14 did not want to be touched in the morning because her shoulder and legs hurt. Upon investigation, it was determined that Nurse Aide 1 got Resident 14 out of bed the morning of July 5, 2023, by herself, without use of mechanical lift, via an unacceptable transfer procedure, and neglected to follow the resident's care plan. Nurse Aide 1 stated, I sat her on the edge of the bed, gave her a bear hug while she was sitting on edge of bed, and transferred her to her wheelchair. Resident 14 had reported to Nurse Aide 1 that her shoulder hurt when she came back from the podiatrist's office on July 5, 2023, but did not inform the licensed practical nurse.
A written statement by Nurse Aide 1, dated July 6, 2023, confirmed that she got Resident 14 out bed the morning of July 5, 2023, by giving hear a bear hug while she was sitting on the edge of the bed and transferred her into her wheelchair. Resident 14 then went to the podiatrist and when she came back, she reported that her shoulder hurt. She was leaning on her left arm while in the wheelchair, was straightened up, and then placed into bed.
The facility's agency employee orientation checklist, dated July 2 2023, revealed that Nurse Aide 1 completed training regarding safety and resident care plan locations, including transfer status.
The facility's investigation, dated July 6, 2023, confirmed that there was evidence of neglect by Nurse Aide 1 due to the fact that she did not use the proper care-planned transfer technique during the morning shift.
Interview with the Nursing Home Administrator on July 18, 2023, at 3:00 pm. and 3:08 p.m. confirmed that Nurse Aide 1 transferred Resident 14 by herself from her bed into the wheelchair instead of using a mechanical lift that was care planned and ordered by the physician, and they feel that is what caused Resident 14's fractures. She indicated that all staff were educated where the resident care plans were located, which included Resident 14's transfer status.
Following the incident on July 5, 2023, the facility's corrective actions included:
Nurse Aide 1, who was involved in the incorrect transfer of Resident 14, was suspended pending the results of the facility's investigation.
On July 6, 2023, a full facility audit of the residents' transfer status was completed. Interviews were completed with residents and families to identify any other incidents of possible neglect. Education was initiated for all staff regarding abuse/neglect and ensuring that proper transfer status was being followed for all residents for the nursing staff.
Review of the facility's education sign-in sheets regarding abuse/neglect indicated that education was completed for the majority of all staff, and review the residents' care plans to ensure the accuracy of the resident's transferring and ambulation status indicated that education was completed for the majority of the nursing staff.
A plan was developed on July 6, 2023, for weekly observations of transfers to be conducted and audits for any abuse/neglect.
The results of the audits were to be discussed during the monthly QA meeting.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on review of clinical records, investigative reports, and staff education, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were us...
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Based on review of clinical records, investigative reports, and staff education, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used in accordance with their care plans and physican's orders for one of 32 residents reviewed (Resident 14) who required the use of a mechanical lift for transfer, resulting in fractured bones for the resident, and to use leg rests to transport one resident out of 32 residents reviewed (Resident 10).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated June 8, 2023, revealed that the resident was cognitively impaired, was dependent on two staff members for transfers, did not ambulate (walk), and had diagnoses that included dementia. The resident's care plan, dated July 20, 2022, revealed that she required a mechanical lift for transfers. An annual therapy screen, dated December 1, 2022, indicated that the resident unable to bear weight and required a mechanical lift for transfers.
A nursing note for Resident 14, dated July 6, 2023, at 9:25 a.m. revealed that the resident complained of pain in the left shoulder. The Certified Registered Nurse Practitioner (CRNP) was notified and orders were received to x-ray the left shoulder.
A CRNP note, dated July 6, 2023, revealed that the resident was seen for complaints of pain to her left shoulder that she was refusing to move. She was also seen for her right knee, which was with purple discoloration, deformity and tenderness. Upon examination the resident had tenderness to her left shoulder and swelling of the right knee with severe pain with any movement. The plan was to x-ray the right hip, femur, knee, leg and ankle regarding pain and deformity.
An x-ray report, dated July 6, 2023, revealed that the resident's left shoulder had a fracture of the surgical neck (the upper arm bone (humerus) closest to the shoulder area) and greater tuberosity (bump of bone at the top of the humerus). An x-ray report, dated July 7, 2023, revealed that the resident had a proximal tibia neck fracture (upper area of the shin bone closest to the knee).
The facility's investigation, dated July 6, 2023, revealed that the daylight nurse aide reported on July 6, 2023, that Resident 14 did not want to be touched in the morning because her shoulder and legs hurt. Upon investigation, it was determined that Nurse Aide 1 got Resident 14 out of bed the morning of July 5, 2023, by herself, without use of mechanical lift, via an unacceptable transfer procedure, and neglected to follow the resident's care plan. Nurse Aide 1 stated, I sat her on the edge of the bed, gave her a bear hug while she was sitting on edge of bed, and transferred her to her wheelchair. Resident 14 had reported to Nurse Aide 1 that her shoulder hurt when she came back from the podiatrist's office on July 5, 2023, but did not inform the licensed practical nurse.
A written statement by Nurse Aide 1, dated July 6, 2023, confirmed that she got Resident 14 out bed the morning of July 5, 2023, by giving hear a bear hug while she was sitting on the edge of the bed and transferred her into her wheelchair. Resident 14 then went to the podiatrist and when she came back, she reported that her shoulder hurt. She was leaning on her left arm while in the wheelchair, was straightened up, and then placed into bed.
The facility's agency employee orientation checklist, dated July 2 2023, revealed that Nurse Aide 1 completed training regarding safety and resident care plan locations, including transfer status.
Interview with the Nursing Home Administrator on July 18, 2023, at 3:00 pm. and 3:08 p.m. confirmed that Nurse Aide 1 transferred Resident 14 by herself from her bed into the wheelchair instead of using a mechanical lift that was care planned and ordered by the physician, and they feel that is what caused Resident 14's fractures. She indicated that all staff were educated where the resident care plans were located, which included Resident 14's transfer status.
The facility's policy regarding foot/leg rests, dated May 12, 2023, indicated that bilateral footrests will be utilized throughout the transport, with resident's lower extremities properly positioned.
A quarterly MDS assessment for Resident 10, dated May 30, 2023, revealed that the resident was cognitively impaired, required extensive assistance of two staff for bed mobility, required one-person physical assist for locomotion on the unit, and had diagnoses that included legal blindness, osteoarthritis and peripheral vascular disease.
Physican's orders, dated June 19, 2023, revealed that the resident was to use leg rests for transport.
Observations on July 18, 2023, at 9:51 a.m. revealed that Nurse Aide 2 pushed Resident 10 down the hall and into the North Lounge in a wheelchair that was not equipped with a leg rests. The resident's feet were approximately two inches above the floor while being transported.
Observations on July 18, 2023, at 9:54 a.m. revealed that Activity Aide 3 immediately noticed that Resident 10 did not have leg rests on the wheelchair and proceeded to take them out of the wheelchair pouch and place them on the wheelchair.
Interview with Nurse Aide 2 at 9:57 a.m. and Activity Aide 3 at 9:59 a.m. confirmed that Resident 10 should not have been transferred without leg rests.
Interview with the Nursing Home Administrator on July 18, 2023, at 2:53 p.m. confirmed that Resident 10 should not have been transported without leg rests.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on review of Pennsylvania's Nursing Practice Act, clinical records, as well as staff interviews, it was determined that the facility failed to correctly transcribe physician's orders for one of ...
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Based on review of Pennsylvania's Nursing Practice Act, clinical records, as well as staff interviews, it was determined that the facility failed to correctly transcribe physician's orders for one of 32 residents reviewed (Resident 58).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 58 dated May 9, 2023, revealed that the resident was able to make himself understood and could understand others, required extensive assistance for personal care needs, and had diagnoses that included chronic obstructive pulmonary disease (COPD- lung disease that blocks airflow and makes it difficult to breathe).
Physician's orders in the Point Click Care electronic record for Resident 58, dated June 27, 2023, included that the resident receive five milliliters (ml) of Vancomycin HCL Oral solution (antibiotic) 250 milligrams (mg)/5ml every six hours for 14 days, and five ml every eight hours for seven days, and five ml two times a day for seven days and five ml one time a day for seven days.
Physician orders in the Matrix electronic record for Resident 58, dated June 27, 2023, included that the resident receive 2.5 ml of Vancomycin 50 mg/ml four times a day for C-Diff for 14 days.
A nurse's note for Resident 58, dated June 26, 2023, at 6:56 p.m., included that the resident was seen by the physician and new orders were received to give 250 mg of Vancomycin by mouth every six hours for two weeks, then every eight hours for one week then twice a day for one week, and then once a day for one week.
The care plan for Clostridium difficile infection for Resident 58, dated June 26, 2023, included that staff administer medication until August 1, 2023, as ordered by physician.
Interview with the Assistant Director of Nursing on July 19, 2023, at 12:54 p.m. confirmed that when the physician's orders were transcribed into the Matrix electronic record, they were transcribed incorrectly causing Resident 58 to not receive Vancomycin as ordered by the physician.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 32 residents...
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Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were followed for two of 32 residents reviewed (Residents 5, 9) and failed to ensure that the physician was notified of lab results for one of 32 residents reviewed (Resident 9).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 14, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff for personal care needs, had one venous ulcer, was receiving hospice services, and had diagnoses that included dementia.
Physician's orders for Resident 5, dated June 28, 2023, included orders to cleanse the right lower leg with wound cleanser, pat dry, apply collagen powder (helps support new skin growth), hydrogel (used to keep wounds clean by promoting removal of infected or dead skin tissue), and cover with adaptic (a dressing used to protect a wound and prevent dressing from sticking to it), an abdominal pad (abd pad- thick dressing used on wounds with drainage) and Kling (rolled gauze) daily and as needed.
Observations of Resident 5 on July 18, 2023, at 9:35 a.m. revealed that the resident was lying in her bed with both legs visible. A dressing was intact to her right lower leg that was initialed and dated July 16, 2023.
A review of the Medication Administration Record (MAR) for Resident 5, dated July 2023, revealed that the dressing to the resident's right lower leg was completed by a nurse with different initials on July 17, 2023.
An interview with Registered Nurse 4 on July 18, 2023, at 9:50 a.m. confirmed that the documentation of Resident 5's dressing change on July 17, 2023, was incorrect. The dressing was documented as completed on July 17, 2023, but it was not completed as ordered by the physician as evidenced by the date on the resident's dressing at the time of the observation as July 16.
The facility's policy for Diagnostic Testing Results, Physician/Extender Notification, dated May 12, 2023, included that it is the policy of the facility to notify the ordering physician or ordering physician extender of all diagnostic testing results. All prothrombin time and international normalized ratio (PT/INR - blood tests that measure how long it takes for blood to clot) results will be called to the physician for further orders prior to the next scheduled dose.
A significant change MDS assessment for Resident 9, dated June 15, 2023, revealed that the resident was cognitively intact, required supervision with personal hygiene needs, required limited assistance from staff for toileting and dressing, had diagnosis that included atrial fibrillation (an irregular, often rapid heart rhythm), and was receiving anticoagulant (a blood thinner) medication.
Physician orders for Resident 9, dated January 29, 2018, included that the resident's Coumadin (an anticoagulant) orders were to be reviewed one time a day every day.
A nursing note for Resident 9, dated February 27, 2023, at 12:21 p.m., as well as a review of lab results, dated February 27, 2023, revealed that new orders were received to hold the resident's Coumadin and recheck her PT/INR in the morning.
A review of laboratory results for Resident 9, dated February 28, 2023, revealed that a PT/INR was obtained and results were reported to the facility; however, there was no documented evidence that the physician was notified of the results or that orders for Coumadin were received.
A review of the MAR for Resident 9 revealed documentation that Coumadin orders were being reviewed every day at 4:00 p.m.; however, the resident did not have any orders for Coumadin and did not receive any Coumadin between February 28, 2023, and March 9, 2023.
An interview with the Director of Nursing on July 20, 2023, at 12:37 p.m. revealed that there was no documented evidence that the physician was notified of Resident 9's lab results on February 28, 2023, and no documented evidence that orders were received for Coumadin therapy and there should have been. It also revealed that the resident had no orders for Coumadin and did not receive any Coumadin between February 28, 2023, and March 9, 2023, confirming that Coumadin orders were not being reviewed every day as ordered by the physician.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potenti...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for one of 32 residents reviewed (Resident 14).
Findings include:
The facility's policy regarding medication management, dated May 12, 2023, revealed that the nurse would document on the Medication Administration Record (MAR) with initials at the appropriate date and time for the medication administered after witnessing the ingestion of the medication.
A significant change minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated July 13, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff for care, had vocal complaints of pain and facial grimacing, received an opioid, received hospice services, and had diagnoses that included dementia.
Physician's orders for Resident 14, dated July 7, 2023, included orders for the resident to receive 0.5 milliliters (mL) of morphine concentrate (a controlled medication used to treat pain) every two hours as needed for moderate pain or respiratory distress and 1.0 mL of morphine concentrate every two hours as needed for severe pain or respiratory distress.
Resident 14's controlled drug accountability records for July 2023 revealed that staff signed out doses of 0.5 mL of morphine concentrate for administration to the resident on July 10 at 12:50 p.m. and July 15 at 1:50 p.m., and signed out 1.0 mL of morphine concentrate for administration to the resident on July 11 at 12:48 p.m. and July 13 at 11:00 p.m.; however, there was no documented evidence in the MAR that the morphine concentrate was actually administered to the resident on the dates and times listed.
Interview with the Director of Nursing and Nursing Home Administrator on July 20, 2023, at 9:13 a.m. confirmed that there was no documented evidence that staff administered signed-out doses of morphine concentrate to Resident 14 on the above dates and times.
28 Pa. Code 211.9(h) Pharmacy services.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 32 residen...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to obtain laboratory studies as ordered by the physician for one of 32 residents reviewed (Resident 8).
Findings include:
The facility's policy regarding prothrombin time and international normalized ration (PT/INR - blood tests that measure how long it takes for blood to clot), dated May 12, 2023, revealed that to better manage residents receiving Coumadin (a blood thinner) therapy, INR values would be monitored to be sure that residents are taking the correct dose and are complying with therapy. The licensed staff will perform INR monitoring as per nursing standards of practice as clinically indicated or as ordered by the physician. The licensed staff will notify the physician/extender of results as indicated.
The facility's policy regarding physician/provider orders, dated May 12, 2023, revealed that the order shall be recorded exactly as the physician dictates it on a phone order form or directly into the electronic health record if not otherwise specified by state regulation.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 11, 2023, revealed that the resident was understood, understands, required extensive assistance from staff for her daily care tasks, and had a diagnosis which included anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells) and Alzheimer's disease. A care plan for the resident, dated March 25, 2022, revealed that the resident was receiving anticoagulant (also known as blood thinners) therapy and staff was to administer the anticoagulant medications as ordered and obtain labs as ordered, reporting any abnormal lab results to the physician.
A nursing note for Resident 8, dated July 10, 2023, revealed that the resident's INR result was 1.6 (normal range is 0.8 - 1.1). (If a patient is on Coumadin, the therapeutic range is 2.0 - 3.0, and a high dose is 2.5 - 3.5). The results were reviewed by the Certified Registered Nurse Practitioner (CRNP - a registered nurse (RN) who has advanced education and clinical training in a health care specialty area) and an order was received for the resident to receive seven milligrams (mg) of Coumadin at bedtime and repeat the INR on July 12, 2023. The resident was aware of the new orders.
Lab results for Resident 8, dated July 10, 2023, revealed that the resident's PT was 18.5 (normal range is 9.4 - 12.5) and an INR of 1.6. Verbal orders received from the CRNP was to increase the Coumadin to seven mg and recheck the resident's PT/INR on July 12, 2023.
Physician's orders for Resident 8, dated July 10, 2023, included an order for the resident to receive seven mg of Coumadin at bedtime. However, there was no documented evidence that the PT/INR was included in the order entered into the resident's electronic medical record or that the PT/INR was obtained on July 12, 2023.
Interview with the Assistant Director of Nursing on July 19, 2023, at 12:55 p.m. and at 1:25 p.m. confirmed that there was no documented evidence that Resident 8 had a PT/INR drawn on July 12, 2023.
28 Pa. Code 211.12(d)(1)(3) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed according to the f...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that long-term intravenous catheters were flushed according to the facility's policy for one of 32 residents reviewed (Resident 16).
Findings include:
The facility's policy regarding flushing of peripheral catheters (a thin tube inserted into a vein and used long-term for the administration of fluids and/or medications), dated May 12, 2023, indicated that a midline catheter was to be flushed before and after the administration of medications.
Physician's orders for Resident 16, dated May 23, 2023, included orders for the resident to receive 1 gram of meropenem solution (antibiotic) intravenously (IV - directly into a vein) two times a day (6:00 a.m. and 6:00 p.m.) for pneumonia until June 6, 2023, and orders dated May 20, 2023, included an order for the IV catheter to be flushed with 3 ml of normal saline before and after medication administration one time a day until May 28, 2023, and for the IV catheter to be flushed with 3 ml of normal saline every shift until May 28, 2023. There was no documented evidence of a physician's order to flush the resident's IV catheter before and after medication administration at 6:00 p.m. or for any time May 28, 2023, through June 6, 2023.
Resident 16's Medication Administration Records (MAR's) for May and June 2023 revealed that the resident received IV meropenem twice a day from May 23 to June 6, 2023; however, there was no documented evidence that staff flushed the resident's IV catheter with normal saline solution before and after the administration at 6:00 p.m. from May 23 through May 28, 2023, or any time from May 28 through June 6, 2023.
Interview with the Nursing Home Administrator on July 20, 2023, at 1:10 p.m. confirmed that there was no documented evidence that Resident 16's IV catheter was flushed pre and post-medication administration at 6:00 p.m. from May 23 through May 28, 2023, or at any time from May 28 through June 6, 2023, and should have been.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant ...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide medication as ordered by the physician, resulting in a significant medication error for three of 32 residents reviewed (Residents 8, 9, 58), which resulted in Resident 8 requiring medical intervention to correct a critically high laboratory result, which increased the resident's risk for bleeding.
Findings include:
The facility's policy regarding prothrombin time and international normalized ration (PT/INR - blood tests that measure how long it takes for blood to clot), dated May 12, 2023, revealed that to better manage residents receiving Coumadin (a blood thinner) therapy, INR values would be monitored to be sure that residents are taking correct dose and are complying with therapy. The licensed staff will perform INR monitoring as per nursing standards of practice as clinically indicated, or as ordered by the physician. The licensed staff will notify the physician/extender of results as indicated.
The facility's policy regarding medication administration, dated May 12, 2023, revealed that licensed staff would administer physician-ordered oral medications following acceptable standards of care.
The facility's policy regarding physician/provider orders, dated May 12, 2023, revealed that the order shall be recorded exactly as the physician dictates it on a phone order form or directly into the electronic health record if not otherwise specified by state regulation.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 11, 2023, revealed that the resident was understood, understands, required extensive assistance from staff for her daily care tasks, and had a diagnosis which included anemia (a condition that develops when your blood produces a lower-than-normal amount of healthy red blood cells) and Alzheimer's disease. A care plan for the resident, dated March 25, 2022, revealed that the resident was receiving anticoagulant (also known as blood thinners) therapy and staff was to administer the anticoagulant medications as ordered and obtain labs as ordered, reporting any abnormal lab results to the physician.
A nursing note for Resident 8, dated July 10, 2023, revealed that the resident's INR result was 1.6 (normal range is 0.8 - 1.1. If a patient is on Coumadin, the therapeutic range is 2.0 - 3.0, and a high dose is 2.5 - 3.5). The results were reviewed by the Certified Registered Nurse Practitioner (CRNP - a registered nurse (RN) who has advanced education and clinical training in a health care specialty area) and an order was received for the resident to receive seven milligrams (mg) of Coumadin at bedtime and repeat the INR on July 12, 2023. The resident was aware of the new orders.
Lab results for Resident 8, dated July 10, 2023, revealed that the resident's PT was 18.5 (normal range is 9.4 - 12.5) and an INR of 1.6. Verbal orders received from the CRNP was to increase the Coumadin to seven milligrams and recheck the resident's PT/INR on July 12, 2023.
Physician's orders for Resident 8, dated July 10, 2023, included an order for the resident to receive seven milligrams of Coumadin at bedtime. However, there was no documented evidence that the PT/INR was included in the order entered into the resident's electronic medical record.
Medication Administration Records (MARs) for Resident 8, dated July 2023, revealed that staff administered the seven milligrams of Coumadin to the resident at bedtime July 10 through 16, 2023.
A nursing note for Resident 8, dated July 17, 2023, revealed that the resident had a critical PT/INR lab result. Lab results for Resident 8, dated July 17, 2023, revealed that the resident's PT was 142.3 (normal range is 9.4 - 12.5) and an INR of 11. Results were called to the CRNP and new orders were received to discontinue the current Coumadin orders, give 10 mg Vitamin K (helps your blood clot so wounds do not bleed too much) as one time dose, repeat the PT/INR in the a.m. and monitor the resident for bleeding.
Interview with the Assistant Director of Nursing on July 19, 2023, at 12:55 p.m. and at 1:25 p.m. confirmed that Resident 8 should have had an INR drawn on July 12, 2023, and that Resident 8 continued to received the seven mg of Coumadin from July 10 through 16, 2023.
A significant change MDS assessment for Resident 9, dated June 15, 2023, revealed that the resident was cognitively intact, required supervision with personal hygiene needs, required limited assistance from staff for toileting and dressing, and had diagnosis that included atrial fibrillation (an irregular, often rapid heart rhythm), and was receiving anticoagulant (blood thinner) medication.
A review of laboratory results for Resident 9, dated February 28, 2023, revealed that a PT/INR was obtained, and results were reported to the facility; however, there was no documented evidence that the physician was notified of the results or that orders for Coumadin (an anticoagulant) were received.
A review of the MAR for Resident 9 revealed documentation that Coumadin orders were being reviewed every day at 4:00 p.m.; however, the resident did not have any orders for Coumadin and did not receive any Coumadin between February 28, 2023, and March 9, 2023.
An interview with the Director of Nursing on July 20, 2023, at 12:37 p.m. revealed that there was no documented evidence that orders were received for Coumadin therapy between February 28, 2023, and March 9, 2023; that the resident did not receive any Coumadin between February 28, 2023, and March 9, 2023; and she should have.
A quarterly MDS or Resident 58 dated May 9, 2023, revealed that the resident was able to make himself understood and understand others, required extensive assistance for personal care needs, and had diagnosis that included chronic obstructive pulmonary disease (COPD- lung disease that blocks airflow and makes it difficult to breathe).
A nurse's note for Resident 58, dated June 26, 2023, at 6:56 p.m., revealed that the resident was seen by the physician and new orders were received to give 250 mg of Vancomycin by mouth every six hours for two weeks, then every eight hours for one week then twice a day for one week, and then once a day for one week. A care plan for Clostridium difficile infection for Resident 58, dated June 26, 2023, included that staff administer medication until August 1, 2023, as ordered by the physician.
Physician's orders in the electronic record for Resident 58, dated June 27, 2023, included orders for the resident to receive 2.5 ml of Vancomycin (50 mg/ml) four times a day for C Diff for 14 days.
Review of the MAR for Resident 58 for July 2023 revealed that the resident received 2.5 ml of Vancomycin (50mg/ml) from July 1-8, 2023, at 8:00 p.m.
Interview with the Assistant Director of Nursing on July 19, 2023, at 12:54 p.m. confirmed that when the physician's orders were transcribed into the electronic record, they were transcribed incorrectly resulting in Resident 58 not receiving the Vancomycin as ordered by the physician.
28 Pa. Code 201.29(d) Resident rights.
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.9(a)(1) Pharmacy services.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of manufacturer's directions for use, as well as observations and staff interviews, it was determined that the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of manufacturer's directions for use, as well as observations and staff interviews, it was determined that the facility failed to discard expired multi-dose Tuberculin vials for one of two medication refrigerators reviewed (Upper Level right medication refrigerator).
Findings include:
Manufacturers's direction for use for Tuberculin (a solution to aid the diagnosis of tuberculosis infection), dated [DATE], revealed that a vial of Tubersol which has been entered and in use for 30 days should be discarded.
Observations of the Upper Level right medication refrigerator on [DATE], at 11:16 a.m. revealed that there were two multidose vials of Tubersol solution on the top shelf of the door in the refrigerator. One Tubersol multidose vial was dated as being opened on [DATE] (42 days after opening), and the second Tubersol multidose vial was dated as being opened on [DATE] (39 days after being opened). Interview with Registered Nurse 5 at the time of observation confirmed that the Tubersol multidose vials were opened and dated with [DATE] and 11, 2023, as the dates that they were opened and that both Tubersol multidose vials should have been discarded.
Interview with the Nursing Home Administrator on [DATE], at 11:34 a.m. confirmed that staff should have discarded the two Tubersol multidose [NAME] after 30 days of being opened.
28 Pa. Code 211.9(a)(1) Pharmacy services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as resident and staff interviews, it was determined that the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for four of 32 residents reviewed (Residents 3, 5, 14, 61).
Findings include:
A facility policy for splint application and removal, dated May 12, 2023, included that nursing staff will apply a splint to the specified area as per physician orders and the nurse will document the total minutes the splint is worn. Licensed staff will document the checking of skin integrity with each application and removal of the splint on the Treatment Administration Record (TAR).
A facility policy for Range of Motion, dated May 12, 2023, indicated that nursing staff are to perform the program as per order with a focus on established goals per acceptable standards. Documentation of the program is to be completed by nursing staff in the electronic health record.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated June 5, 2023, revealed that the resident was able to make himself understood and understood others, required extensive assist of staff for personal hygiene needs, was dependent on staff for transfers and dressing, and had diagnoses that included atherosclerotic heart disease (damage or disease in the heart's major blood vessels caused by a buildup of plaque, resulting in limited blood flow to the heart).
Physician's orders for Resident 3, dated March 29, 2023, included an order for the resident to wear a left palm guard for four hours every shift. A care plan for activities of daily living (ADL) for Resident 3, dated October 29, 2022, indicated that the resident was to wear a left palm guard with finger separators for four hours each shift.
A review of clinical record for Resident 3 for July 2023 revealed that no documentation was present on July 3, 7, 8, 9, and 13 for day shift; July 1, 2, 4, 7-12, and 14-17 for evening shift; and July 2, 4-13, and 17, for night shift, of the left palm guard being applied or refused by the resident.
Interview with the Nursing Home Administrator on July 20, 2023, at 2:08 p.m. confirmed that documentation regarding Resident 3's left palm guard was not completed correctly. Documentation should have been completed every shift to reveal if the left palm guard was applied or refused by the resident but was not.
A quarterly MDS assessment for Resident 5, dated May 14, 2023, revealed that the resident was cognitively impaired, required extensive assist from staff for personal care needs, had one venous ulcer, was receiving hospice services, and had diagnosis that included dementia.
Physician orders for Resident 5, dated June 28, 2023, included to cleanse the right lower leg with wound cleanser, pat dry, apply collagen powder (helps support new skin growth), hydrogel (used to keep wounds clean by promoting removal of infected or dead skin tissue), cover with adaptic (a dressing used to protect a wound and prevent dressing from sticking to it), abdominal pad (ABD pad - thick dressing used on wounds with drainage) and Kling (rolled gauze) daily and as needed.
Observations of Resident 5 on July 18, 2023, at 9:35 a.m. revealed that the resident was lying in her bed with both her legs visible. A dressing was intact to her right lower leg that was initialed and dated July 16.
A review of the Medication Administration Record (MAR) for Resident 5, dated July 2023, revealed that the dressing to the resident's right lower leg was completed by a nurse with different initials on July 17, 2023.
An interview with Registered Nurse 4 on July 18, 2023, at 9:50 a.m. confirmed that the documentation of Resident 5's dressing change on July 17, 2023, was incorrect. The dressing was documented as completed on July 17, but it was not completed as evidenced by the date on the resident's dressing at the time of the observation as being July 16.
The facility's policy regarding specialty mattress utilization, dated May 12, 2023, revealed that the facility would utilize specialty mattresses for any resident deemed clinically appropriate, with no contraindications, for the use of wound healing.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated June 8, 2023, revealed that the resident was cognitively impaired, required extensive assistance from staff for bed mobility, was dependent on two staff members for transfers, did not ambulate (walk), and had diagnoses that included dementia. A care plan, dated March 27, 2023, revealed that the resident used a specialty air mattress.
There was no documented evidence in the clinical record that an air mattress safety assessment was completed.
Observations of Resident 14 on July 19, 2023, at 11:10 a.m. revealed the resident was in bed and had an air mattress in place.
A hospice note, dated July 19, 2023, indicated that Resident 14 was safe in bed with the use of a low air loss mattress.
An interview with the Nursing Home Administrator on July 20, 2023, at 9:11 a.m. confirmed that there no was no documented evidence of an air mattress safety assessment in Resident 14's medical record and that they had no access to the hospice note regarding the resident being safe in bed with an air mattress.
An admission MDS assessment for Resident 61, dated July 4, 2023, revealed that the resident could make herself understood and understood others, was cognitively intact, required extensive assist from staff for personal care needs, only ambulated once or twice with set-up help, and had a history of falls.
A therapy Discharge summary, dated [DATE], revealed that the resident met her maximum potential and was to be referred for the restorative nursing program. There was no documented evidence that Resident 14 was receiving restorative nursing.
Interview with Resident 61 on July 20, 2023, at 11:29 a.m. revealed that nobody was walking her and she wanted to walk.
Interview with the Nursing Home Administrator on July 20, 2023, at 1:10 p.m. confirmed that there was no documented evidence that Resident 14 was receiving restorative nursing due to the recent switch of electronic medical records but indicated that she was receiving restorative nursing.
28 Pa Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending July 28, 2022, and a complaint investigation survey ending February 28, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending July 20, 2023, identified repeated deficiencies related to the failure to provide professional nursing services, failure to provide quality nursing care, safety/accidents, intravenous therapy, and resident records.
The facility's plan of correction for a deficiency regarding professional nursing services, cited during the survey ending July 28, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F658, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding professional nursing services.
The facility's plan of correction for a deficiency regarding quality care, cited during the survey ending February 28, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality care.
The facility's plans of correction for deficiencies regarding providing a safe environment free of accident hazards, cited during the survey ending July 28, 2022, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding safety and accident-free environments.
The facility's plan of correction for a deficiency regarding a failure ensure that intravenous therapy was completed correctly, cited during the survey ending on July 28, 2022, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F694, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding intravenous therapy.
The facility's plan of correction for a deficiency regarding a failure ensure that the medical records were complete and accurate, cited during the survey ending on July 28, 2022, revealed that audits would be conducted, and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F842, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding complete and accurate medical records.
Refer to F658, F684, F689, F694, F842.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on review of facility policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread...
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Based on review of facility policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related to an Extended Spectrum Beta-Lactamase (ESBL- Beta-lactamases are enzymes produced by some bacteria that may make them resistant to some antibiotics) infection in the urine for one of 32 residents reviewed (Resident 15).
Findings include:
The facility's Infection Prevention and Control policy, dated May 12, 2023, revealed that contact precautions are intended to prevent the transmission of infectious agents which are spread through direct or indirect contact with the patient or the patient's environment. Contact precautions also apply where the presence of excessive wound drainage, urine or fecal incontinence, or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Enhanced barrier protections are intended to prevent transmission of multi-drug resistant organisms (MDRO's-bacteria that have become resistant to certain antibiotics) via contaminated hands and clothing of healthcare workers to high-risk residents.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated June 9, 2023, revealed that the resident was able to make herself understood and could sometimes understand others, required extensive assistance for daily care needs, was frequently incontinent of bowel and bladder, and had diagnoses that included urinary tract infection and MDRO infection.
Review of the final urine culture and sensitivity (laboratory test to attempt to grow bacteria and then test which medications will effectively work to stop the infection) laboratory results for Resident 15, dated June 26, 2023, revealed that the resident's urine culture was positive for ESBL producing Escherichia coli. A final urine culture and sensitivity laboratory result, dated July 3, 2023, revealed the resident's urine culture was positive for ESBL producing Escherichia coli.
A review of the clinical record, including physician orders, nurse's notes and care plans, for Resident 15, dated June 2023 and July 2023, revealed that as of July 19, 2023, there was no evidence that any precautions were ordered or implemented to prevent the transmission of the residents ESBL infection.
Observations of Resident 15 on July 17, 18, and 19, 2023, revealed that there was no signage to alert staff and visitors of contact precautions for the resident and no observations that contact precautions were being implemented when providing care to the resident.
Interview with the Director of Nursing/Infection Control Nurse on July 20, 2023, at 1:20 p.m. confirmed that contact isolation precautions were never initiated after Resident 15's urine laboratory results showed a positive ESBL infection, but should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Feb 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representativ...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to provide the required notice to the resident or the resident's representative regarding the potential liability of payment for when Medicare coverage was ending for one of three residents reviewed (Resident 2).
Findings include:
The facility's policy regarding advance beneficiary notices, dated January 23,2023, indicated that a notice of Medicare non-coverage was required to notify beneficiaries of their right to an expedited review process when the facility anticipated that the coverage of their skilled services would end. The facility should provide the resident of his/her potential liability of payment of an item or service that is usually paid for by Medicare with a form called Skilled Nursing Facility Advance Beneficiary Notice (ABN).
A resident profile for Resident 2, dated November 9, 2017, revealed that the resident's primary payer was Medicare A. It was also noted that on January 21, 2023, he was Medicare pending.
The notice of Medicare non-coverage form for Resident 2 indicated that his coverage would end on January 20, 2023.
There was no documented evidence that Resident 2 and/or his legal representative was provided with an ABN to inform them of the potential liability of payment when his Medicare coverage was ending.
Interview with the Nursing Home Administrator on February 28, 2023, at 2:50 p.m. confirmed that she could not provide documented evidence that Resident 2 was provided with the ABN notice.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of the clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a consultant physician's recommendation was communicated to the attendin...
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Based on review of the clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a consultant physician's recommendation was communicated to the attending physican timely for one of three residents reviewed (Resident 2).
Findings include:
A diagnosis record for Resident 2, dated February 11, 2023, included anxiety and major depressive disorder.
A psychiatric consult report for Resident 2, dated Febraury 3, 2023, indicated that the resident was seen due to anxiety and depression. This resident has a long history of alcohol, anxiety and depression. He wanted to handle his mental health now since he no longer drinks. The consult report was signed by the psychiatrist on February 3, 2023, at 2:25 p m. However, the form was signed noted by the registered nurse on February 11, 2023. Physician's orders, dated February 11, 2023, (eight days after seen by the psychiatrist) included an order for Resident 2 to receive 15 milligrams of Remeron every evening at bedtime for depression.
Interview with the Director of Nursing on February 28, 2023, at 2:50 p.m. revealed that with the help of the social worker, the psychiatrist conducts telehealth visits and then he sends all of his consult reports to her. The Director of Nursing confirmed that the report should have been communicated timely to nursing in order to notify the physician of the medication recommendation.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure the provision of restorative nursing to maintain and/or to prevent a decline in...
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Based on a review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure the provision of restorative nursing to maintain and/or to prevent a decline in range of motion for two of three residents reviewed (Residents 1, 2).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated December 9, 2022, indicated that he was alert and oriented; had no rejections of care; required extensive assistance of two for bed mobility, transfers, dressing, hygiene and toilet use; and was receiving restorative nursing for active range of motion, walking, dressing and eating. The plan of care for Resident 1, dated October 29, 2022, indicated that he was to be provided a restorative nursing program (RNP-a program of care which is intended to restore a lost ability or maintain a potentially deteriorating function) for active range of motion (AROM- assisted exercises to keep the joints flexible) to his upper and lower extremities, eating/swallowing, dressing/grooming, and transfers.
The restorative documentation for Resident 1 from January 30 through February 28, 2023, revealed no documented evidence that AROM was provided as care planned on the evening shift of February 3, 5, 6, and 7, 2023; that AROM for eating/swallowing was provided as care planned during lunch on February 17 and 24, and supper on February 6, 7, and 17, 2023; that AROM for dressing/grooming was provided as care planned on the evening shift of February 3, 5, 6, and 7, 2023; or that AROM for transfers was provided as care planned on the day shift of February 1 and 7, and the evening shift of February 3, 5, 6, 7, and 10, 2023.
An admission MDS assessment for Resident 2, dated January 9, 2023, indicated that he was alert and oriented, had no rejections of care, required assistance of one for bed mobility and assist of two for transfers.
A therapy discharge summary for Resident 2, dated January 20, 2023, indicated that he was to remain in long-term care with Restorative Nursing Programs. The plan of care for Resident 2, dated January 23, 2023, indicated that he was to be provided restorative nursing for AROM of his bilateral upper and lower extremities and for ambulation of 200 feet utilizing a wheeled walker and stand-by assistance.
The restorative documentation for Resident 2's AROM for January 31, 2023, to February 27, 2023, indicated that it was not applicable for the evening shift on February 3, 5, 6, and 7 and on the day shift on February 26, 2023. Restorative ambulation was documented as not applicable for the evening shift on February 3, 5 , 6, 25, and for the day shift on February 12, 13, 15, 16, and there was no documented evidence of the provision of RNP on February 7, 10, 26, 2023.
Interview with the Restorative Nurse 1 on Febraury 28, 2023, confirmed that Resident 2 should be provided restorative two times a day and they should not document not applicable unless they document the reason it was not provided. She confirmed there was no documented evidence that these residents were provided or why they were not provided their RNP as per their care plans.
28 Pa. Code 211.12(d)(5) Nursing services.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 41% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 4 harm violation(s), $32,394 in fines. Review inspection reports carefully.
- • 48 deficiencies on record, including 4 serious (caused harm) violations. Ask about corrective actions taken.
- • $32,394 in fines. Higher than 94% of Pennsylvania facilities, suggesting repeated compliance issues.
- • Grade F (10/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Harmon House Health & Rehab Center's CMS Rating?
CMS assigns HARMON HOUSE HEALTH & REHAB 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 Harmon House Health & Rehab Center Staffed?
CMS rates HARMON HOUSE HEALTH & REHAB CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 41%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Harmon House Health & Rehab Center?
State health inspectors documented 48 deficiencies at HARMON HOUSE HEALTH & REHAB CENTER during 2023 to 2025. These included: 4 that caused actual resident harm and 44 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Harmon House Health & Rehab Center?
HARMON HOUSE HEALTH & REHAB CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by SABER HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 109 certified beds and approximately 102 residents (about 94% occupancy), it is a mid-sized facility located in MOUNT PLEASANT, Pennsylvania.
How Does Harmon House Health & Rehab Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, HARMON HOUSE HEALTH & REHAB CENTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (41%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Harmon House Health & Rehab Center?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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?" These questions are particularly relevant given the substantiated abuse finding on record.
Is Harmon House Health & Rehab Center Safe?
Based on CMS inspection data, HARMON HOUSE HEALTH & REHAB CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Harmon House Health & Rehab Center Stick Around?
HARMON HOUSE HEALTH & REHAB CENTER has a staff turnover rate of 41%, 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 Harmon House Health & Rehab Center Ever Fined?
HARMON HOUSE HEALTH & REHAB CENTER has been fined $32,394 across 4 penalty actions. This is below the Pennsylvania average of $33,403. 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 Harmon House Health & Rehab Center on Any Federal Watch List?
HARMON HOUSE HEALTH & REHAB 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.