MAPLEWOOD NURSING AND REHAB CENTER
For profit - Individual
180 Beds
BEDROCK CARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
28/100
#310 of 653 in PA
Photo by Kevin Cooley
Photo by Kevin Cooley
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Last Inspection: August 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Maplewood Nursing and Rehab Center has received a Trust Grade of F, indicating poor performance with significant concerns. They rank #310 out of 653 facilities in Pennsylvania, placing them in the top half, but their grade suggests they have serious issues to address. The facility is showing an improving trend, having reduced their issues from 35 in 2024 to just 5 in 2025. Staffing is a weakness here, with a rating of 2 out of 5 stars and a turnover rate of 55%, which is above the state average of 46%, meaning staff may not stay long enough to build relationships with residents. Additionally, the facility has incurred fines totaling $106,422, which is concerning as it is higher than 87% of Pennsylvania facilities, indicating repeated compliance problems. Specific incidents found during inspections included a failure to maintain safe water temperatures in resident bathrooms, putting residents at risk for burns, and a serious incident where a resident sustained burns from a hot beverage due to inadequate monitoring. There were also concerns regarding food safety practices in the kitchen, including improper food storage and cleanliness issues. While there are serious weaknesses, it is important to note that the facility is making efforts to improve and is located in a relatively good ranking position within the state.
- Trust Score
- F
- In Pennsylvania
- #310/653
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 55% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $106,422 in fines. Higher than 77% of Pennsylvania facilities, suggesting repeated compliance issues.
- Skilled Nurses ⚠ Watch
- Each resident gets only 27 minutes of Registered Nurse (RN) attention daily — below average for Pennsylvania. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 43 deficiencies on record. Higher than average. Multiple issues found across inspections.
28/100
Top 47%
Review needed
35 → 5 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 35 issues
2025: 5 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near Pennsylvania average (3.0)
Meets federal standards, typical of most facilities
Staff Turnover: 55%
Near Pennsylvania avg (46%)
Higher turnover may affect care consistency
Federal Fines: $106,422
Well above median ($33,413)
Significant penalties indicating serious issues
Chain: BEDROCK CARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 43 deficiencies on record
1 life-threatening 1 actual harm
Aug 2025
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
Based on staff and resident interviews and review of clinical records, it was determined that the facility failed to ensure that documented room change notifications to the resident and/or emergency c...
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Based on staff and resident interviews and review of clinical records, it was determined that the facility failed to ensure that documented room change notifications to the resident and/or emergency contact were provided for one out of 33 residents reviewed (Resident R133).Findings include:During an interview with Resident R133 on August 27, 2025, at 2:07 p.m. stated facility moved his room without providing prior notice. The resident stated the staff came into his room and asked him to move. The resident stated he was not prepared and did not pack his belongings, and staff did not give him the opportunity to do it himself because it was important for him to pack his belongings himself.Review of room change notification for Resident R133 dated February 19, 2025, revealed that resident had room change on February 19, 2025, and the date of notification was on February 19, 2025. The question for written copy provided to was answered N/A (Not Applicable Resident is alert and oriented X3.Further review of clinical records revealed no evidence that the facility provided written notice to the resident prior to the room change.Interview with Administrator on August 28, 2028 at 11:00 a.m. confirmed that the facility did not provide written notice to Resident R133 when his room was changed on February 19, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee28 Pa. Code 201.29(c.3) (1) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to th...
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Based on review of facility policies and clinical records and staff interviews, it was determined that the facility failed to ensure that a written summary of the baseline care plan was provided to the resident and/or the resident's representative for one of two residents reviewed (Resident R151).Findings include:Interview Resident R151 on August 26, 2025, at 11:00 a.m. stated he was not provided a copy of the baseline care plan or medication list since his admission.A review of Resident R151's clinical record reviewed that the resident was July 28, 2025.Review of the clinical record for Resident R151 revealed no evidence that the facility provided a written summary of baseline care plan and a medication list to the resident or the resident representative.Interview with the Social Service Director, Employee E8 on August 28, 2025, at 9:54 a.m. confirmed that the facility did not provide a written copy of baseline care plan to Resident R151 or his representative. Employee E9 also stated that the facility did not have a process of providing a copy of the baseline care plan or medication list28 Pa Code 211.10(a) Resident care policies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to update resident's physician o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to update resident's physician orders related to dialysis schedule for one of one resident review receiving hemodialysis treatment (Resident R8). Findings Include: Review of the medical record revealed that Resident R8 was admitted on [DATE], with diagnosis including, but not limited to end stage renal disease (the final stage of chronic kidney disease, where kidneys can no longer function adequately, requiring dialysis or a kidney transplant for survival). Further review of the clinical record for Resident R8 revealed a July 25, 2025, physician's order for hemo dialysis at a local dialysis center with a 10:00 a.m. chair time every Monday, Wednesday and Friday. Interview with the Unit Clerk, Employee E7 on the second floor on August 28, 2025, at 9:30 a.m. revealed that Resident R8 was not on the floor and was at dialysis. When asked why he was at dialysis on a Thursday when his order was for Monday, Wednesday and Friday, she indicated that Resident R8 has been going four days a week for the past few weeks. When asked about the physician's order she got the Unit Manager, Employee E4, who confirmed that the order needed to be updated to include four days a week adding Thursdays to the order. A review of Resident R8's nursing progress notes revealed that the resident was at dialysis on Thursday August 14, 2025, and Thursday August 21, 2025. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3) Management 28 Pa. Code 211.12(c) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of...
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Based on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of four residents sampled for post-traumatic stress disorder(PTSD) care for one of 33 residents reviewed. (Resident R4).Findings include:A review of the clinical record revealed that Resident R4 was admitted to the facility, with diagnoses to include traumatic subdural hemorrhage(a collection of blood that accumulates between the inner layer of the skull (dura mater) and the surface of the brain after a head injury), major depressive disorder (a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels that can significantly impact daily life and post-traumatic stress disorder (PTSD) ( a mental health condition that develops after experiencing or witnessing a traumatic event, such as a natural disaster, war, violent crime, or personal loss).A quarterly Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) for Resident R4 dated May 23, 2025, Section I, Active Diagnoses, Psychiatric/Mood Disorder, question I6100, indicated the resident has post-traumatic stress disorder (PTSD).Resident R4's current care plan, dated June 17, 2025, revealed a care plan for history of traumatic event. Further review of the care plan did not address possible triggers that may cause re-traumatization.Interview with the Social Service Director, Employee E9, on August 28, 2025, at 9:54 a.m confirmed that Resident R4's care plan for PTSD did not include resident's possible triggers that may cause re-traumatization. 28 Pa. Code 211.12(c)(d)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to offer and/or provide the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to offer and/or provide the influenza and pneumococcal immunization for three of five residents reviewed (Resident R43, R55 and R151).The findings include:Review of the clinical record for Resident R43 revealed the resident was admitted to the facility on [DATE]. The resident was [AGE] years old.Review of R43's immunization records revealed no evidence that the resident received the influenza vaccine, or the facility offered the influenza vaccine.Review of the clinical record for Resident R55 revealed the resident was admitted to the facility on [DATE]. The resident was [AGE] years old.Review of R55's immunization records revealed no evidence that the resident received the influenza vaccine, or the facility offered the influenza vaccine.Review of the clinical record for Resident R151 revealed the resident was admitted to the facility on July28, 2025. The resident was [AGE] years old.Review of R151's immunization records revealed no evidence that the resident received the pneumococcal vaccine, or the facility offered the pneumococcal vaccine.28 Pa Code: 201.14 (a ) Responsibility of licensee28 Pa Code: 201.12 (d)(1) Nursing services
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review a facility policy, review of facility documentation, review of clinical records, and interviews with staff, it w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review a facility policy, review of facility documentation, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that a resident was safely transfer via mechanical lift for one of four residents reviewed. (Resident R1)
Findings include:
Review of facility policy titled Mechanical Lift updated April 2023, revealed that initially the staff must review the resident's care plan to assess for any special needs of the resident and if warranted, assemble the equipment and supplies as needed. Further steps in the procedure to transfer a resident from a bed to a chair must follow guidelines of operation including that one nursing assistant or licensed nurse shall control the lift to prevent tilting, and lift bar from striking resident etc, the second nursing assistant or licensed nurse must be in control of the resident and repositioning. The general guidelines requires two nursing assistants and or two licensed staff will be required to perform the procedure .
Review of Resident R1's Minimum Data Set (MDS- federal mandated assessment tool that measures health status of all residents) dated September 27, 2024 revealed that the resident was admitted to the facility on [DATE], with diagnoses of' atrophy (muscle mass loss due to neurogenic conditions), dysphasia (difficulty swallowing food or liquid), dementia (loss of memory, language, problem solving, nd other thinking abilities), and malnutrition (a condition that occurs when the body does not get the right amount of nutrients needs to function properly). Continue review of the MDS revealed that Resident 1 was totally dependent for transfers and required a wheelchair.
Review of Resident R1's nursing evaluation dated December 21, 2024 revealed that the resident mobility was assessed as requiring a mechanical lift to transfer the resident from one surface to another by two staff.
Observation outside Resident R1's room on December 30, 2024 at 11:05 a.m. revealed nurse aide, Employee E2 transferring Resident R1 by mechanical lift from bed to wheelchair. Employee E2 was the only employee in the room transferring the resident.
Interview with Employee E2 at time of the above observation revealed that this employee was aware the the mechanical lift required a two person assists. Employee E2 stated that another employee was assisting but left the room.
Review of facility inservice attendance record for transfers via hoyer lift dated September 2024 revealed that all nursing assistants were educated on the proper usage of a mechanical lift for residents that require transfers via mechanical lift based on facility policy . Transfer competencies were completed for all nurse aides educated on where to find the resident transfer status on residence [NAME].
Further review of the facility inservice attendance record for transfers revealed that nurse aide, Employee E2 and Licensed nurse, Employee E3 signed the document that they were educated on the hoyer lift.
Interview with Employee E3 on December 30, 2024 at 11:12 a.m. revelaed that the employee left Employee E2 and Resident R1 to attend to another resident. Employee E3 confirmed that it is not the policy to leave an employee to transfer a resident without assistance.
28 Pa. Code 201.20 (a)(6) Staff development
28 Pa. Code 211.12 (d)(1)(2)(5) Nursing Services
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of facility provided documentation, interview with staff and review of clinical record, it was determined that facility failed to ensure that require information to obtain an imaging s...
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Based on review of facility provided documentation, interview with staff and review of clinical record, it was determined that facility failed to ensure that require information to obtain an imaging study was submitted for one out of nine residents reviewed. (Resident R4)
Findings include:
Review of Resident R4's clinical record that the resident was admitted to facility on January 27, 2023 with medical history of left basal ganglia, intraparenchymal hemorrhage (bleeding within brain parenchyma), status post craniectomy, stroke affecting right dominant side, cognitive communication deficit, encounter for surgical aftercare following surgery on the nervous system, depression, aphasia (difficulty speaking), dysphagia (difficulty swallowing),and gastrostomy status.
Review of facility provided documentation revealed Resident R4 had left decompressive hemicraniectomy (neurosurgical procedure that removes part of the brain) completed prior to admission to facility, on January 2, 2023.
On April 16, 2024, Resident R4 had consult regarding neurosurgery with recommendation for stealth CT ordered for prosthetic manufacturing.
Further review of Resident R4's clinical record revealed that on May 7, 2024, nurse aide Employee E3, contacted Resident R4's insurance company regarding stealth CT scan, - many times to see if the scan had gotten approved. There is no accurate information at the moment because they never received the information as requested. I will re-fax the information to the insurance company.
Further review of Resident R4's clinical record revealed that on May 24, 2024, nurse aide - Employee E3, contacted Resident R4's insurance company regarding CT scan of abdomen/pelvis with and without contrast, for which insurance company denied service and will not approve due to lack of medical information.
Reviewed facility provided note from department of neurosurgery, dated April 26, 2024, which indicates that [Resident R4] requires a stealth CT scan to have a PEEK customized implant manufactured for his reconstructive cranioplasty
Per phone interview with Resident R1's insurance company representatives on Wednesday, December 11, 2024 at 11:22 AM, and again at 11:35 AM, revealed that Resident R4 does not have any medical information submitted on his behalf in order to be approved for stealth CT scan and CT scan for abdomen/pelvis. Further interview with representatives revealed that insurance company requires Resident R4's prior imaging tests that show a need for further imaging, any current or completed treatment for the problem, and any lab work up, scope study, or physical exams.
Facility was unable to provide evidence that required medical information was submitted to Resident R4's insurance company.
Interview on December 11, 2024 with the facility's Administrator and Assistant of Director of Nursing confirmed the findings.
28 Pa. Code 211.12(d)(1) Nursing services
Nov 2024
21 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility policies, and staff interviews, it was determined that the PASRR (Preadmiss...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, review of facility policies, and staff interviews, it was determined that the PASRR (Preadmission Screen and Resident Review) was not appropriately revised according to the resident assessment for one of three residents reviewed. (Resident R77)
Findings include:
Review of facility policy titled Pre-admission Screening and Resident Review (PASRR) program dated April 1, 2022, reveled the facility work will coordinate assessments with the preadmission screening and resident review program. The coordination includes incorporating the recommendations from the pass our level to determination and pass our evaluation report into a resident assessment care planning and transition of care also to referring all level two residents and all red and all residents with newly evident or possible serious mental disorder intellectual disability or a relation condition for level two resident review upon a significant change in status assessment. Continued review of this policy revealed a nursing facility must notify the state mental health authority or state intellectual disability authority as applicable promptly after a significant change in the mental or physical condition of a resident who is a mental illness or intellectual disability for resident review.
The PASRR pre-admission screening resident review was created in 1987 through language in the omnibus budget reconciliation act (OBRA) And it has three goals to identify individuals with mental illness and or intellectual disability, to ensure they are placed appropriately, whether in the community or in a nursing facility, and to ensure they receive the services they require for their mental illness or intellectual disability.
The PASRR level I must be completed on all persons who are considering admission to a Medicaid certified nursing facility. A level II PASRR evaluation must be completed at the level 1 PASRR determined that the person is a targeted person with mental illness or intellectual disabilities. The level II PASRR will determine if placement or a continued stay in the requested or carrot nursing facility is appropriate.
Review of Resident R77 quarterly MDS dated [DATE], revealed that Resident R77 had diagnosis including Dementia, Depression (mental health disorder characterized by persistently depressed mood and loss of interest), Bipolar disease (a mental illness that causes extreme mood swings, or shifts in energy, thinking, behavior and sleep), and psychotic disorder (mental illness characterized by a disconnection from reality which includes hallucinations, delusions, disorganized thoughts, speech and actions).
Review of Resident R77's care plan revealed that this resident had the potential to be aggressive related to mental emotional illness, diagnosis of major depression disorder and unspecified delusional disorder, unspecified psychosis and other psychotic disorders dated August 5, 2020.
Review of Resident R77's PASRR level I assessment dated [DATE] revealed the resident did not have any serious mental illnesses listed on the assessment continue review revealed that the assessment was signed and completed July 21, 2017, by facility staff.
Interview with Nursing Home Administrator, Employee E1 November 5, 2024, revealed that this above PASRR for Resident 77 was the most current PASRR.
28 Pa. Code 201.8(b)(1) Management
28 Pa. Code 201.8 (e) (1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical records reviews, it was determined that the facility failed to develop a baseline care plan with...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical records reviews, it was determined that the facility failed to develop a baseline care plan within 48 hours of admission that includes the instructions needed to provide effective and person-centered care, ADL (activity of daily living) needs for one of 32 residents reviewed (Resident R362).
Findings include:
Observation conducted of Resident R362 on November 3, 2024, at 9:10 a.m. revealed that Resident R362's left hand was in a fist. Further, Resident R362 had unkempt facial hair.
Review of clinical record revealed that Resident R362 was admitted to the facility on [DATE], with diagnoses of Cerebral Infarction (stroke) due to embolism to the right vertebral artery, aphasia (difficulty speaking and trouble understanding), and cerebral atherosclerosis (thinking and hardening of brain arteries).
Review of Resident R362's OSA (OSA- Optional State Assessment, a state required MDS-minimum data set assessment containing the activities of daily living (ADL) functional items) MDS (minimum data set, a federally required resident assessment completed at a specific interval) assessment dated [DATE], section G (Functional Status), G0110. (Activities of Daily Living (ADL) Assistance),
Bed mobility - how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture was coded 3 for self-performance and 2 for support extensive assistance with 1-person physical assist,
Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing, was coded 3 for self-performance and 2 for support extensive assistance with 1-person physical assist,
Toilet use - how resident uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self after elimination; changes pad; manages ostomy or catheter; and adjusts clothes was coded 3 for self-performance and 2 for support extensive assistance with 1-person physical assist,
Further review of Resident R362's clinical record revealed that there was no base line care plan for ADL developed within 42 hours of admission. Further a care plan for ADL self-care performance deficit r/t (related to) Impaired balance was developed and initiated on October 23, 2024, five days after Resident R362 was admitted to the facility.
28 Pa. Code 211.5(f)(viii) Medical records
28 Pa. Code 211.12(d)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, and staff and resident interviews, it was determined that the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of clinical records, and staff and resident interviews, it was determined that the facility failed to ensure residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of five residents reviewed with limited range of motion (Resident R38).
Findings Include:
Review of Resident R38's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 16, 2024, revealed the resident was cognitively intact and had diagnoses of hemiplegia (paralysis of one side of the body), muscle wasting, and muscle weakness.
Further review of Resident R38's quarterly MDS dated [DATE], revealed the resident had impairment in range of motion on one side of the upper extremity.
Observations on November 3, 2024, at 12:50 p.m. revealed Resident R38 had a contracture (shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult) of the left-hand and had no splint.
Resident R38 reported that he used to have a splint for the left-hand contracture but was unsure what happened to it.
Interview on November 6, 2024, at 9:26 a.m. with licensed nurse, Employee E18, confirmed Resident R38 had a left-hand contracture. Further interview with licensed nurse, Employee E18, believed that Resident R38 used to have a splint but was unsure.
Interview on November 5, 2024, at 12:45 p.m. with Physical Therapist, Employee E21, revealed the employee started in September of 2024 and did not have access to previous therapy treatment notes for Resident R38.
Interview on November 5, 2024, at 12:50 p.m. with Occupational Therapist, Employee E35, revealed the employee's first day was November 4, 2024, and was not familiar with Resident R38 and treatment for the left hand contracture.
Interview on November 6, 2024, at 9:26 a.m. with Restorative Nurse Aide, Employee E34, confirmed Resident R38 had a splint at one time but was not put on a restorative nursing program.
Review of Resident R38's entire clinical record revealed no documented evidence of the treatment and services Resident R38 received for the left hand contracture.
28 Pa. Code 211.12 (d)(3) Nursing services.
28 Pa. Code 211.12 (d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to ensure communication with the dialysis provider for one of two residen...
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Based on review of clinical records, review of facility policy and staff interview, it was determined that the facility failed to ensure communication with the dialysis provider for one of two residents reviewed on renal dialysis (Resident R22)
Findings include:
Review of facility policy title Dialysis dated April 1, 2022, revealed that the facility shall provide adequate management of dialysis services to ensure that residents attained or maintain the highest practicable physical mental and psychosocial wellbeing. Further review of this policy reveal the facility will ensure that residents who require dialysis receive such services consistent with professional standards of practice the comprehensive standard care plan and residence goals and preferences. The nursing facility will collaborate with the dialysis facility and assure that residents needs related to dialysis or met. That documentation requirements are met to assure that treatments are provided as ordered and nephrologist attending practitioners and dialysis team. That there is an ongoing communication and collaboration for the development and implementation of dialysis care plan by nursing home and dialysis staff
Continued review of this policy revealed the facility must provide ongoing communication and collaboration between the nursing home and the dialysis provided regarding dialysis care and services assessment of the resident's condition. Ongoing monitor from complications before and after dialysis treatments. The facility will utilize the Dialysis Communication from each time a resident attends dialysis as a tool to relay permanent information regarding the residents condition and coordinate care and services with the dialysis provider
Review of Resident R22's annual Minimum Data Set (MDS - federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing facility) dated October 16, 2024, revealed Resident R22 entered the facility on November 16, 2023 with the diagnosis of end stage renal disease (a medical condition in which a person's kidney ceases functioning on a permanent basis leading to the need for regular course of long term dialysis or kidney transplant to maintain life), and dependent on dialysis (the process of removing waste products and excess fluid from the body dialysis is necessary when kidneys are not able to adequately filter the blood).
Review of Resident R 22's documented dialysis communication binder revealed that the daily documented pages included instructions to record both weights, pre and post treatment. The daily pages also included any instructions, recommendations for care, any access problems, administered medications, lab work or any concerns before, during and after treatment.
Review of treatment dates daily communication pages revealed incomplete communication:
October 30, 2024, the documented page did not contain any dialysis assessment nor dialysis nurse signature.
October 23, 2024, the documented page did not include any facility pretreatment documentation and any vitals. Continued review of this document revealed there was no dialysis assessment completed nor dialysis nurse signature.
October 21, 2024, the documented page did not include any dialysis assessment completed nor dialysis nurse signature.
October 11, 2024, the documented page did not include any pre or post treatment weights and did not include any dialysis assessment completed nor the dialysis nurse signature.
October 9, 2024, the documented page did not include any pre or post treatment weights, and did not include any dialysis assessment completed, or the dialysis nurse signature.
October 7, 2024, the documented page did not include any dialysis assessment completed or the dialysis nurse signature.
October 2, 2024, the documented page did not include any pre or post treatment weights and did not include any dialysis assessment completed or the dialysis nurse signature.
September 30, 2024, the documented page did not include any pre or post treatment weights and did not include any dialysis assessment completed, or the dialysis nurse signature.
The above observation was confirmed by Licensed nurse, unit manager Employee E32. Employee E 32 stated that she has been in communication with the dialysis staff regarding the incomplete documentation.
28 Pa. Code 211.12(d)(1) Nursing Services
28 Pa. Code 211.12(d)(3) Nursing Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure a medication error rate of less than five pe...
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Based on observations, review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure a medication error rate of less than five percent for two of four residents observed during medication administration (Residents R43 and R108).
Findings include:
The facility's medication error rate was 20.69 percent based on observation of 29 medication administration opportunities with six medication errors observed.
Review of facility policy, Administering Medication dated April 17, 2024, revealed, Medications shall be administered in a safe and timely manner, and as prescribed.
Review of facility policy, Enteral Feeding dated April 15, 2024, revealed, Prior to crushing tablets for administration through the enteral tube, the Medication Crushing General Guidelines should be reviewed. Continued review revealed, Each medication is administered separately followed by a 5cc [milliliter] flush of water between medications to avoid physical interactions of the medications.
Observation of the morning medication pass on November 3, 2024, at 9:51 a.m. Employee E26, licensed nurse, prepared medications for Resident R43. Employee E26, licensed nurse, prepared one tablet of enteric coated 81 m.g (milligrams) of aspirin (a medication to prevent and to treat heart attacks, to prevent strokes, and to treat inflammation), two tablets of delayed release 20 m.g omeprazole (medication used to treat acid reflux) for a total of 40 m.g, one tablet of 50 m.g sertraline (medication used to treat depression), one tablet of 50 m.g topiramate (medication used to treat seizures) and 17 grams of polyethylene glycol powder mixed in a cup of water (laxative medication).
Review of physician orders for Resident R43 revealed an order, dated August 11, 2023, for aspirin 81 m.g chewable tablet via PEG tube (percutaneous endoscopic gastrostomy - a surgical opening and placement of a tube though a person's abdominal wall into their stomach). Continued review revealed another order, dated February 2, 2024, for omeprazole suspension give 40 m.g via PEG tube two times a day.
Employee E26, licensed nurse, proceeded to crush Resident R43's aspirin, omeprazole, sertraline and topiramate tablets together, then poured the crushed tablets into the polyethylene glycol water solution. Employee E26, licensed nurse, then administered the medications to Resident R43 via her PEG tube.
Employee E26, licensed nurse, stated that Resident R43 gets her medications crushed and administered through her PEG tube, that what's in the medication cart are the only medications that she has and that she has to crush some medications even though they aren't supposed to be crushed.
Continued observation of the morning medication pass on November 3, 2024, at 10:24 a.m. Employee E25, licensed nurse, prepared medications for Resident R108. Employee E25, licensed nurse, prepared 17 grams of polyethylene glycol powder mixed in a cup of water. Employee E25, licensed nurse, prepared the rest of Resident R108's medications and administered them with the prepared polyethylene glycol.
Review of physician orders for Resident R108 revealed that there were no orders for polyethylene glycol for the resident.
Employee E25, licensed nurse, stated that she administered the polyethylene glycol because Resident R108 requested something to help move his bowels.
28 Pa Code 211.9(a)(1) Pharmacy services
28 Pa Code 211.10(c) Resident care policies
28 Pa Code 211.12(d)(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 observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to ensure that medications were properly labeled and dated for two of three medication carts reviewed (fourth floor A and B carts), and failed to ensure that a medication cart was kept locked when not in use during medication administration for one of three nursing units observed (third floor nursing unit).
Findings include:
Review of facility policy, Administering Medication dated April 17, 2024, revealed, During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. Continued review revealed, Medications must be stored per manufacturer/labeled.
Review of facility policy, Medication Storage dated April 1, 2022, revealed, Medications will be stored in the original, labeled containers received from the pharmacy.
Review of facility policy, Expiration Dates for Open Injectable Diabetes Medications dated July 12, 2023, revealed that lispro (rapid acting) and lantus (long acting) insulin vials (medications used to lower blood sugar levels) expire 28 days after the vials are opened and that aspart (rapid acting) insulin pens also expire 28 days after the pens are opened.
Observation on November 3, 2024, at 9:51 a.m. of the fourth floor unit B (high side) medication cart with Employee E26, licensed nurse, revealed a vial of lispro for Resident R44 that was open and undated. Continued observation of the medication cart revealed two vials of lantus insulin that were opened and had no label nor date of when the vials were opened. Employee E26, licensed nurse, confirmed the above findings at the time of the observation.
Observation on November 3, 2024, at 10:24 a.m. of the fourth floor unit A (low side) medication cart with Employee E25, licensed nurse, revealed two vials of lantus insulin for Resident R129 that were opened and undated. Continued observation revealed an opened aspart insulin pen for Resident R129 that was open and undated. Continued review revealed a vial of lispro insulin for Resident R98 that was open and undated. Further review revealed two medication cups that were unlabeled, one cup contained one unmarked pill and the other cup contained six unmarked capsules; Employee E25, licensed nurse, stated that the one pill was senna (laxative medication) for a resident and that the six capsules were probiotics for another resident. Employee E25, licensed nurse, confirmed the above findings at the time of the observation.
Observation of medication cart B on the third-floor nursing unit on November 4, 2024, at 9:48 a.m. revealed the cart was positioned between rooms [ROOM NUMBERS] with cart drawers facing outward. The medication cart was observed unlocked. Licensed nurse Employee E33, assigned to this cart was in room [ROOM NUMBER] with the room door closed, obstructing any visual of the medication cart.
Observation on Licensed nurse, Employee E33 exiting room [ROOM NUMBER] on November 4, 2024, at 9:59 a.m The medication cart was left unlocked and unattended for ten minutes.
Interview with Rmployee E33 on November 4, 2024, at 9:59 a.m. confirmed that the facility policy of locking the medication carts is that the medication carts must be locked at all times. Employee E33 stated she was room [ROOM NUMBER] providing care for the resident.
28 Pa Code 211.9(a)(1) Pharmacy services
28 Pa Code 211.12(d)(2) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected 1 resident
Based on review of personnel files, review of facility documentation, and staff interviews, it was determined that the facility failed to employ a qualified Registered Dietitian and Director of Food a...
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Based on review of personnel files, review of facility documentation, and staff interviews, it was determined that the facility failed to employ a qualified Registered Dietitian and Director of Food and Nutrition Services.
Findings Include:
Review of the job description for the Director of Food and Nutrition Services revealed that job responsibilities included oversight of ordering, receiving, storing, preparation and service of food.
Interview on November 4, 2024, at 11:45 a.m. with Registered Dietitian, Employee E8, confirmed the Registered Dietitian only worked at the facility part time.
Review of Food Service Directors, Employee E4, personnel file revealed the employee held the position of Dietary Director with a start date of July 17, 2023.
Review of the Food Service Directors, Employee E4, personnel file confirmed the employee was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution.
Review of Food Service Directors, Employee E4's, credentials indicated that Employee E4 did not meet the statutory qualifications of a director of food and nutrition services.
Review of the Registered Dietitian, Employee E8, personnel file revealed the employee held the position of Registered Dietitian with a start date of April 3, 2023.
Further review of Registered Dietitian, Employee E8, personnel file revealed no documented evidence that the employee was licensed as a dietitian by the State of Pennsylvania (LDN - Licensed dietitian-nutritionist).
Interview on November 5, 2024, at 12:05 p.m. with Regional Registered Dietitian, Employee E19, confirmed Registered Dietitian, Employee E8, was not licensed by the State of Pennsylvania, as required, to practice dietetics-nutrition in the Commonwealth of Pennsylvania.
28 Pa. Code 201.14 (a) Responsibility of licensee.
49 Pa. Code 21.701 Definitions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected 1 resident
Based on observations and staff interviews, it was determined that the facility failed to employ sufficient dietary personnel to carry out the functions of the food and nutrition service for one of on...
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Based on observations and staff interviews, it was determined that the facility failed to employ sufficient dietary personnel to carry out the functions of the food and nutrition service for one of one meal observed (Breakfast November 3, 2024).
Findings Include:
Observation on November 3, 2024, revealed that the posted mealtimes on the fourth-floor nursing unit were: Breakfast 7:40 a.m. to 8:40 a.m.
Observations in the main kitchen on November 3, 2024, at 9:00 a.m. revealed dietary staff were preparing for the breakfast meal service and cooking food. Observations revealed there was one dietary personnel cooking the breakfast and three dietary aides preparing the resident beverages and meal trays for service.
Interview on November 3, 2024, at 9:00 a.m. with the Assistant Food Service Director, Employee E24, revealed the cook did not show for the breakfast shift. Observations revealed breakfast was still being prepared by the Assistant Food Service Director, Employee E24, at 9:15 a.m.
Further observations on November 3, 2024, revealed breakfast tray line (when resident trays began to get plated) started at 9:35 a.m. in the main kitchen.
Observations on November 3, 2024, revealed residents did not start receiving breakfast until about 9:50 a.m.
Interview on November 3, 2024, at 10:30 a.m. with the Food Service Director, Employee E4, revealed there are usually/supposed to be four dietary aides to work the breakfast meal service but only three were working the breakfast meal.
Further observations on November 3, 2024, revealed the last nursing unit to receive breakfast, 4th floor nursing unit, did not get their last truck of breakfast trays until 11:05 a.m.
28 Pa Code 201.18(b)(3) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility documentation, and staff and resident interviews, it was determined that the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility documentation, and staff and resident interviews, it was determined that the facility failed to ensure menus were followed for three of three nursing units observed (second, third and fourth floor nursing units).
Findings include:
Review of the facility menu revealed the planned menu for lunch on November 3, 2024, was crispy ranch chicken, oven browned potatoes, and parslied carrots. The alternate planned lunch items were roast pork, rice pilaf, and brussels sprouts.
Observations on November 3, 2024, at 2:00 p.m. in the main kitchen revealed dietary staff was serving beef stew over rice.
Interview on November 3, 2024, at 2:00 p.m. with the Food Service Director, Employee E4, confirmed the planned menu was not followed because there was not sufficient time to prepare the meal due to breakfast running so late.
Review of the facility menu revealed the planned menu for lunch on November 4, 2024, was fish, orzo, and sauteed mushrooms. The alternate planned lunch items were meatballs with gravy, chateau potatoes, and baked zucchini.
Interview on November 4, 2024, at 12:27 p.m. with the Food Service Director, Employee E4, revealed mushrooms would not be served because the residents do not like it. The Food Service Director, Employee E4, reported a California vegetable blend was the substitution.
Observations of tray line in the main kitchen on November 4, 2024, at 12:45 p.m. with the Food Service Director, Employee E4, confirmed meatballs with gravy and chateau potatoes was the alternate lunch option. Observations revealed zucchini was not available as a side option per the planned menu.
Observations on November 4, 2024, at 12:55 p.m. revealed the residents in room [ROOM NUMBER]-A bed and 210-B bed received meatballs with orzo, not potatoes, per the planned menu.
Interview with Resident R309, room [ROOM NUMBER]-B bed, on November 4, 2024, at 12:55 p.m. revealed he would have liked the potatoes instead of the orzo.
Observation on November 3, 2024, at 9:11 a.m. of the menu posted on the fourth floor nursing unit revealed that oat cereal, egg of choice, biscuit, margarine, jelly, coffee, tea, milk, orange juice, sugar, salt, pepper and nondairy creamer were on the menu to be served for breakfast. Fried chicken, poultry gravy, mashed potatoes, seasoned cabbage, wheat roll, margarine, cranberry bar, coffee, tea, milk, sugar, salt, pepper, nondairy creamer and a parsley garnish were to be served for lunch. The alternate lunch meal was posted as beef and rice casserole with seasoned zucchini.
Continued observation revealed that the breakfast meal trays were served on the fourth floor nursing unit on November 3, 2024, at 10:58 a.m. Residents were served pancakes with syrup, scrambled eggs, trix cereal, coffee, sugar, nondairy creamer and milk. Observations of residents' meal tickets revealed that residents were supposed to receive orange juice and bran flakes cereal with their meals; however, no residents received these items. Further observation revealed that Resident R137's meal ticket indicated that the resident was supposed to receive a mighty shake nutritional supplement with her meal but received a snack pack pudding cup instead. Residents R63 and R127 stated that the meal was terrible.
Continued observation revealed that the lunch meal trays were served on the fourth floor nursing unit on November 3, 2024, at 2:05 p.m. Residents were served beef stew over rice or chili over rice, carrots, a dessert of either pineapple, pears or pudding, cranberry juice, and coffee. Residents who received the beef stew were also served a dinner roll.
Interview with on November 3, 2024, at 11:05 a.m. with Resident R40's daughter revealed that her mother has not been getting her Ensure Clear supplement on her tray, and that she has been buying it because it is one of the only things that she will consume. Review of Resident R40's meal ticket revealed that Ensure Clear was listed on the ticket. Observation of Resident R40's tray revealed that there was not Ensure Clear on her tray.
Interview with Employee E27, Nurse Aide, revealed that the Ensure Clear had not been coming up on the meal trays.
Interview with Employee E4, Food Service Director (FSD), confirmed that she has been having trouble order enough Ensure Clear in the past few weeks or so, and that they had run out again that morning at breakfast.
Interview with Resident R91, on November 3, 2024, at 11:25 a.m. revealed that he does not like the food, and sometimes he does not get what is listed on the ticket, like no orange juice on his breakfast tray today.
28 Pa. Code 211.6(a) Dietary services
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(3) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that food was palatable and served at appetizing temperatures.
Findings include:
Rev...
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Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that food was palatable and served at appetizing temperatures.
Findings include:
Review of facility food council minutes dated September 25, 2024, revealed old business that was reviewed included cold food temperatures. Further review of the food council minutes revealed 9 out of 11 residents reported the temperature of hot and cold foods at breakfast were not appropriate.
Review of facility food council minutes dated October 30, 2024, revealed food temperatures are still served cold for breakfast. Further review of the food council minutes revealed 7 out of 7 residents reported breakfast is served cold.
Observation of the breakfast meal served on the fourth floor nursing unit on November 3, 2024, at 10:58 a.m. revealed that residents were served pancakes with syrup, scrambled eggs, trix cereal, coffee, sugar, nondairy creamer and milk.
Interview on November 3, 2024, at 10:58 a.m. Resident R63 stated that the pancake was cold, that the coffee was cold, that the eggs were always bad and he refused to eat them.
Interview on November 3, 2024, at 11:10 a.m. Resident R127 stated that the breakfast tasted terrible.
Interview on November 3, 2024, at 12:12 p.m. Resident R159 stated that the food was terrible.
Interview on November 3, 2024, at 12:18 p.m. Resident R111 stated that the food was horrible.
Interview on November 4, 2024, at 9:43 a.m. Resident R62 stated that the food sucks.
Interview with Resident R91, on November 3, 2024, at 11:25 a.m. revealed that he does not like the food, that it is disgusting, not always hot enough, and he worries about not getting enough to eat.
Observations on November 3, 2024, at 10:45 a.m. revealed dietary staff utilized a tray line system to plate resident meals in the kitchen before loading onto a food cart and sending resident meal trays to the designated nursing units. Further observations revealed dietary staff used a steam table to hold the foods while serving on the tray line.
Interview on November 3, 2024, at 10:45 a.m. with the Food Service Director, Employee E4, revealed the steam table has been broken for a few months and does not work to help keep foods warm on the steam table while serving. Further interview with the Food Service Director, Employee E4, revealed the plate warmer (used to warm plates to help keep food warm during meal service) was also broken.
A test tray was completed on November 3, 2024, at 11:05 a.m. with Food Service Director, Employee E4, on the fourth-floor nursing unit, during the breakfast meal service. The outcome of the test tray revealed the following: pureed pancakes were 100.8 degrees Fahrenheit (F), minced and moist pancakes were 107.2 degrees F, scrambled eggs were 101.5 degrees F, regular pancakes were 91 degrees F, and the juice was 66.9 degrees F. A taste test of the food items revealed the food was served cold to taste.
Interview with the Food Service Director, Employee E4, on November 3, 2024, at 11:05 a.m. confirmed that the hot foods were served too cool to be palatable and that the cold beverage was served too warm.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 211.6(f) Dietary services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected 1 resident
Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to prepared foods in a form that meet resident needs for 8 of 8 residents on a...
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Based on observations, review of facility documentation, and staff interviews, it was determined that the facility failed to prepared foods in a form that meet resident needs for 8 of 8 residents on a pureed diet (Resident R100, R124, R21, R148, R8, R138, R81, R53).
Findings Include:
Review of facility diet manual signed by the Medical Director on January 1, 2023, and signed by the Food Service Director on September 1, 2023, revealed the facility follows the International Dysphagia Diet Standardization Initiative (IDDSI - provides a common terminology to describe food textures and drink thickness) Framework for food and beverage consistencies.
Continued review of the facility diet manual revealed IDDSI Level 4 -Pureed Diet are foods pureed which are of a smooth, homogenous, and cohesive consistency and keep their shape when on a spoon.
Review of a physician diet order report provided by the Food Service Director, Employee E4, on November 3, 2024, at 9:50 a.m. revealed Resident R100, R124, R21, R148, R8, R138, R81, and R53 were ordered a pureed diet.
Interview on November 3, 2024, at 9:30 a.m. with the Assistant Food Service Director, Employee E24, revealed the breakfast menu was eggs, pancakes, cold cereal, and hot cereal (oatmeal) for residents on a pureed diet and those who request it.
Observations revealed the Assistant Food Service Director, Employee E24, began plating resident breakfast trays on tray line on November 3, 2024, at 9:35 a.m. Further observations revealed there was only one pan of regular scrambled eggs. Subsequent interview with the Assistant Food Service Director, Employee E24, reported the regular scrambled eggs were also for the residents on a pureed diet and that it was the same thing.
Observations revealed when the scrambled eggs were plated, they were in a crumbly consistency and did not have a smooth, homogenous, and cohesive consistency.
Interview on November 3, 2024, at 9:48 a.m. with the Food Service Director, Employee E4, confirmed the pureed eggs were not prepared in accordance with the diet manual and IDDSI framework.
Interview and observations with the Food Service Director, Employee E4, on November 3, 2024, at 10:42 a.m. revealed the hot oatmeal was lumpy and not prepared into a pureed consistency.
28 Pa. Code 201.14(a) Responsibility of licensee.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0807
(Tag F0807)
Could have caused harm · This affected 1 resident
Based on observations, review of clinical record, and staff interview, it was determined that the facility failed to provide beverages consistent with resident needs for two of twenty-seven residents ...
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Based on observations, review of clinical record, and staff interview, it was determined that the facility failed to provide beverages consistent with resident needs for two of twenty-seven residents reviewed for dining (Resident R152 and R145).
Findings include:
Observation of breakfast meal service conducted on November 3, 2024, at 10:20 am revealed that Resident R152 was in the dining room.
Further observation revealed that Resident R152's meal ticket indicated No Dairy Products.
Observation of Resident R152's breakfast tray revealed that the breakfast tray contained a carton of whole milk.
Interview with Resident R152 conducted at the time of the observation revealed that she is lactose intolerant and that she had requested for almond milk or other non-dairy products but has not received any.
Observations and review of Resident R145's meal ticket on November 4, 2024, revealed the meal ticket specified to provide the resident with thickened beverages.
Review of Resident R145's physician order summary revealed a diet order dated August 6, 2024, which indicated the resident was ordered thin liquids.
Interview on November 5, 2024, at 1:00 p.m. with the Speech Therapist, Employee E37, confirmed Resident R145 was ordered thin liquids for beverages.
Interview on November 5, 2024, at 9:19 a.m. with Licensed Nurse, Employee E18, confirmed Resident R145's meal ticket had the wrong beverage consistency listed. Further interview with the Licensed Nurse, Employee E18, confirmed the kitchen still sends thickened beverages even though the physician ordered thin liquids for Resident R145.
28 Pa. Code 211.10 (c) Resident care policies.
28 Pa. Code 211.12 (d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected 1 resident
Based on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that meals were served timely on three of three nu...
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Based on observations, review of facility documentation and interviews with residents and staff, it was determined that the facility failed to ensure that meals were served timely on three of three nursing units observed (second, third and fourth floor nursing units) and failed to ensure that residents were provided snacks for two of 32 residents reviewed (Residents R68 and R34)
Findings include:
Observation on November 3, 2024, at 9:11 a.m. revealed that posted meal times on the fourth floor nursing unit were: Breakfast 7:40 a.m. to 8:40 a.m.; Lunch 12:15 p.m. to 1:15 p.m.; Dinner 5:50 p.m. to 6:50 p.m.
Review of facility food council minutes dated September 25, 2024, revealed 11 out of 11 residents reported breakfast is usually served late.
Review of facility food council minutes dated October 30, 2024, revealed 7 out of 7 residents reported breakfast is usually served late.
Observations in the main kitchen on November 3, 2024, at 9:00 a.m. revealed dietary staff were preparing for the breakfast meal service and cooking food. Observations revealed there was one dietary personnel cooking the breakfast and three dietary aides preparing the resident beverages and meal trays for service.
Interview on November 3, 2024, at 9:00 a.m. with the Assistant Food Service Director, Employee E24, revealed the cook did not show for the breakfast shift. Observations revealed breakfast was still being prepared by the Assistant Food Service Director, Employee E24, at 9:15 a.m.
Further observations on November 3, 2024, revealed breakfast tray line (when resident trays began to get plated) started at 9:35 a.m. in the main kitchen.
Observations on November 3, 2024, revealed residents did not start receiving breakfast until about 9:50 a.m.
Further observations on November 3, 2024, revealed the last nursing unit to receive breakfast, 4th floor nursing unit, did not get their last truck of breakfast trays until 11:05 a.m.
Interview on November 3, 2024, at 9:27 a.m. Resident R104 stated that she was hungry and that she was upset because breakfast had not been served yet.
Interview on November 3, 2024, at 10:35 a.m. Resident R5 stated that she was hungry and asked when breakfast would be served.
Continued observation revealed that the breakfast meal was delivered to the fourth floor nursing unit on November 3, 2024, at 10:58 a.m.
Further observation revealed that the lunch meal was delivered to the fourth floor nursing unit on November 3, 2024, at 2:05 p.m.
Clinical record review for Resident R68 revealed a nutrition assessment, dated June 21, 2024, which indicated that the resident should receive snacks twice per day. Review of Resident R68's care plan, dated February 27, 2023, revealed that the resident has a nutritional problem and for the resident to receive snacks at 10 a.m., 2 p.m. and at bedtime.
Clinical record review for Resident R34 revealed a nutrition assessment, dated September 17, 2024, which indicated that the resident should receive snacks three times per day. Review of Resident R34's care plan, dated February 12, 2023, revealed that the resident has a nutritional problem and for the resident to receive snacks at 10 a.m., 2 p.m. and at bedtime.
Interview on November 4, 2024, at 10:20 a.m. Employee E28, unit clerk, confirmed that none of the residents on the fourth floor nursing unit received their 10:00 a.m. and 2:00 p.m. snacks on November 3, 2024, because snacks were never sent up from the kitchen.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa.Code 201.18(b)(3) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to submit complete records related to rehabilitation services for...
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Based on review of facility documentation, review of clinical records, and staff interview, it was determined that the facility failed to submit complete records related to rehabilitation services for three of 32 residents reviewed (Resident R110, R113, R38).
Findings include:
Request for rehab documents for Resident R113 on November 6, 2024, at 1:10 pm for Resident R113 revealed that the facility was not able to provide surveyors with rehab notes as requested for Residents Resident R133.
Request for rehab documents for Resident R110 on November 6, 2024, at 1:10pm for Resident R110 revealed that the facility was not able to provide surveyors with rehab notes as requested for Residents Resident R110.
Interview with Employee E1 conducted on November 6, 2024, at 1:11pm revealed that the facility changed rehab company and that they were not able to access the rehab therapy notes from the previous company.
A request for Resident R38's most recent physical and occupational therapy notes and discharge summary was made to the Nursing Home Administrator, Employee E1, on November 6, 2024, at 9:30 a.m.
Interview on November 6, 2024, at 12:45 a.m. with Physical Therapist, Employee E21, revealed the employee started in September 2024 and did not have access to any previous therapy notes for Resident R38 due to a change in ownership.
Interview on November 6, 2024, at 1:00 p.m. with the Nursing Home Administrator, Employee E1, confirmed the facility was unable to obtain and provide physical and occupational therapy notes for Resident R38 as requested.
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa Code: 201.18 (b)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0847
(Tag F0847)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility documents and resident clinical records and interviews with staff, it was determined that the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility documents and resident clinical records and interviews with staff, it was determined that the facility failed to ensure that residents had the capacity to understand the terms of a binding arbitration agreement for one of nine residents reviewed (Resident R259).
Findings include:
Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment
Review of admission record indicated Resident R259 was admitted to the facility on [DATE].
Review of Resident R259's Minimum Data Set (MDS - a periodic assessment of care needs) dated January 17, 2021, indicated the diagnoses of cognitive communication deficit (problem with one or more cognitive skills involved in communication, such as attention, memory, or reasoning). Further review revealed a BIMS score of 3, indicating severe cognitive impairment.
Review of Resident R259's Binding Arbitration Agreement (a binding agreement by the parties to submit to arbitration all or certain disputes which have arisen or may arise between them in respect of a defined legal relationship, whether contractual or not. The decision is final, can be enforced by a court, and can only be appealed on very narrow grounds) indicated that he signed the document on admission on [DATE].
Interview on November 5, 2024, with the Nursing Home Administrator (NHA) revealed that the Arbitration Agreement is part of the admission packet, and that the admission Director gets the signatures at admission. The NHA further stated that the facility did not currently have an admission Director, and that there have been four admission directors since 2021. The NHA confirmed that a resident with a BIMS of 3 should not have been signing this document as they did not have the capacity to understand the terms of a binding arbitration agreement.
28 Pa. Code: 201.14(a)(c)(d)(e) Responsibility of licensee.
28 Pa. Code: 201.18(e)(1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that essential dining equipment in the kitchen and essential resident equipment was ...
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Based on observations and interviews with residents and staff, it was determined that the facility failed to ensure that essential dining equipment in the kitchen and essential resident equipment was maintained in proper working order for two of 32 residents reviewed (Residents R26 and R38).
Findings include:
Interview on November 3, 2024, at 12:50 a.m. with Resident R38 revealed the head rest of the wheelchair fell off and now there is no where to put his head when leaning back.
Interview on November 5, 2024, at 12:45 a.m. with Physical Therapist, Employee E21, confirmed Resident R38's head rest fell off the wheelchair and a maintenance request was sent to the Nursing Home Administrator, Employee E1, on November 1, 2024.
Interview on November 6, 2024, at 9:47 a.m. with the Nursing Home Administrator, Employee E1, confirmed Resident R38's headrest on the wheelchair was broken and that maintenance has not yet looked at the wheelchair for repair.
Observations on November 3, 2024, at 10:45 a.m. revealed dietary staff utilized a tray line system to plate resident meals in the kitchen before loading onto a food cart and sending resident meal trays to the designated nursing units. Further observations revealed dietary staff used a steam table to hold the foods while serving on the tray line.
Interview on November 3, 2024, at 10:45 a.m. with the Food Service Director, Employee E4, revealed the steam table has been broken for a few months and does not work to help keep foods warm on the steam table while serving. Further interview with the Food Service Director, Employee E4, revealed the plate warmer (used to warm plates to help keep food warm during meal service) was also broken.
Continued interview on November 3, 2024, at 10:45 a.m. with the Food Service Director, Employee E4, revealed the slicer in the kitchen was broken.
Continued observations on November 3, 2024, at 11:00 a.m. during a tour of the main kitchen with the Food Service Director, Employee E4, revealed the front panel of the fryer was broken, exposing the inside of the fryer.
Observations of the dish machine on November 3, 2024, at 11:15 a.m. revealed a significant amount of water was spraying through the curtain during use of the dishwasher.
Interview on November 6, 2024, at 12:05 p.m. with the Food Service Director, Employee E4, revealed the dishwasher becomes backed up due to a plumbing issue, causing water to pour out from underneath the dishwasher and onto the floor, subsequently causing the floor to become flooded with inches of water during use of the dishwasher. Further interview and observations also revealed the sink in the dishwasher area has a large crack in it, causing water to leak and further contributing to a flooded floor.
Continued interview on November 6, 2024, at 12:05 p.m. with the Food Service Director, Employee E4, revealed the garbage disposal in the sink is also broken causing water to back up and needing to be plunged frequently.
Observation on November 3, 2024, at 10:40 a.m. revealed Resident R26 had an air mattress that was alarming low pressure. Upon touching the mattress, the metal base under the mattress could be felt. Employee E25, licensed nurse, confirmed that the air mattress was alarming for low pressure and stated that she would recheck the mattress again later.
Continued observation, on November 3, 2024, at 12:25 p.m. revealed that Resident R26's air mattress was still alarming for low pressure. Resident R26 stated that she felt like she was lying on a metal frame and stated that her rear end and back really hurts me.
Continued observation, on November 4, 2024, at 9:47 a.m. revealed that Resident R26's air mattress was still alarming for low pressure. Resident R26 stated that her mattress felt very uncomfortable.
Continued observation, on November 5, 2024, at 10:09 a.m. revealed that Resident R26's air mattress was still alarming for low pressure and the mattress appeared deflated under the resident. Resident R26 stated that her bed felt uncomfortable.
Interview on November 6, 2024, at 9:00 a.m. Employee E30, licensed nurse, confirmed that Resident R26's air mattress has been malfunctioning for the past few days.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0922
(Tag F0922)
Could have caused harm · This affected 1 resident
Based on observation of the facility's physical environment and interviews with staff, it was determined that the facility failed to ensure that a supply of potable (safe for drinking) water on hand a...
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Based on observation of the facility's physical environment and interviews with staff, it was determined that the facility failed to ensure that a supply of potable (safe for drinking) water on hand at the facility in the event that there was a loss of normal water supply.
Findings Include:
Interview on November 6, 2024, at 11:15 a.m. with the Food Service Director, Employee E4, revealed based on a census of 156 residents, the facility should have 3-gallons of water per resident for emergency purposes. Further interview revealed based on the above information the facility should have a total of 468 gallons of emergency water.
Observations of the emergency water storage on November 6, 2024, at 11:30 a.m. with the Food Service Director, Employee E4, revealed the facility only had 294 gallons of emergency water on hand. Interview with the Food Service Director, Employee E4, confirmed the facility did not have sufficient emergency water to meet the needs of the residents in case of an emergency.
28 Pa. Code 201.18(b)(3) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
Based on observations, review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective pest control program in the kitchen and for two o...
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Based on observations, review of facility documentation and interviews with staff, it was determined that the facility failed to maintain an effective pest control program in the kitchen and for two of 32 residents reviewed (Resident R81 and R309).
Findings include:
Review of the facility pest control report dated October 28, 2024, revealed the pest control company
Observed live roach activity in the dishwasher area coming out of wheel carts that carry dishes after they are done being washed. Observed carts with old food on them as well. Subsequently the pest control company recommended for better sanitation practices throughout the kitchen, especially behind the cooking area such as stoves, and for trash to be thrown out in a timely manner. The pest control company also recommend for leaks under dishwasher area to be fixed as the water washes away chemicals after being treated.
Review of the facility pest control report dated November 4, 2024, revealed the pest control copy observed positive roach acceptance on monitor placed under dishwasher area in the main kitchen. The pest control company further recommend better sanitation practices in kitchen and for trash to be thrown out in a timely manner.
Observations during a tour of the main kitchen on November 3, 2024, with the Food Service Director, Employee E4, at 9:45 a.m. revealed the following:
Observations of the cooking equipment such as the fryer, stove, and tilt skillet, revealed they were dirty with significant grease build up on the front of the equipment.
Observations in the dry storage room revealed a plastic bin filled with condiment packets and a red liquid build-up in the bottom of the bin.
Observations behind the ice machine revealed a pool of water on the floor with fruit flies present around the ice machine. Interview with the Food Service Director, Employee E4, revealed the floor drain backs up causing an overflow of water onto the floor.
Observations of the three-compartment prep sink revealed a black bin with water pooled at the bottom and shelf stable milks in the bin. Fruit flies were observed hovering the bin.
The above observations were confirmed by the Food Service Director, Employee E4, during the duration of the tour.
Interview on November 6, 2024, at 12:05 p.m. with the Food Service Director, Employee E4, revealed the dishwasher becomes backed up due to a plumbing issue, causing water to pour out from underneath the dishwasher and onto the floor, subsequently causing the floor to become flooded with inches of water during use of the dishwasher. Further interview and observations also revealed the sink in the dishwasher area has a large crack in it, causing water to leak and further contributing to a flooded floor.
Although the pest control company recommended for leaks under dishwasher area to be fixed as the water washes away chemicals after being treated, the dishwasher is still broken and subsequently flooding the floors.
Observation of wound care for Resident R81 on November 3, 2024, at 1:45 p.m. revealed Employees E10 and E12, licensed nurses, perform wound care on the resident's right foot. The resident was also observed to have an indwelling feeding tube. Continued observation during the treatment revealed multiple flies were in the room and on the resident. Employee E12, licensed nurse, confirmed that there were flies in the room and on Resident R81, and stated that she was unsure when pest management services are provided in the facility and that resident rooms are only treated upon request. Employee E12, licensed nurse, agreed that flies in the room and on the resident puts Resident R81 at greater risk for infection due to having the wound and feeding tube.
Continued observation on November 4, 2024, at 9:55 a.m. revealed that there were multiple flies on Resident R81 and in the resident's room.
Further observation on November 5, 2024, at 10:15 a.m. revealed that there were multiple flies on Resident R81 and in the resident's room.
Review of facility pest logs revealed that no flies were reported on the log for Resident R81.
Observations on November 4, 2024, at 12:57 p.m. revealed Resident R309's bilateral lower extremities were wrapped with gauze and scabs were present on the uncovered areas. Flies were observed in the room at this time. Resident R309 reported that the flies were bothersome.
Interview on November 4, 2024, at 12:59 p.m. with licensed nurse, Employee E36, confirmed Resident R309 had open areas of the bilateral lower extremities and further confirmed the presence of flies in Resident R309's room.
Review of pest control reports revealed that during pest management services that were provided on November 4, 2024, that no resident rooms were treated due to no list of rooms needing treatment were provided to the pest management company.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies, clinical record review and interviews with staff, it was determined that the facility failed to develop comprehensive person-centered care plans, related to behaviors, nutrition and contractures, for four of 32 residents reviewed (Residents R129, R100, R117 and R38).
Findings include:
Review of facility policy, Baseline Care Plan, Comprehensive Care Plan and Ongoing Care Plan Updates dated April 1, 2022, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.
Review of Resident R38's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated September 16, 2024, revealed the resident had diagnoses of hemiplegia (paralysis of one side of the body), muscle wasting, and muscle weakness.
Further review of Resident R38's quarterly MDS dated [DATE], revealed the resident had impairment in range of motion on one side of the upper extremity.
Observations on November 3, 2024, at 12:50 p.m. revealed Resident R38 had a contracture (shortening and tightening of muscle fibers that reduces flexibility and makes movement difficult) of the left-hand.
Interview on November 6, 2024, at 9:26 a.m. with licensed nurse, Employee E18, confirmed Resident R38 had a left-hand contracture.
Review of Resident R38's entire clinical record revealed no documented evidence that the facility developed and implemented a comprehensive care plan pertaining to the care and treatment of Resident R38's left-hand contracture.
Review of Resident R129's Annual MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated September 18, 2024, revealed that the resident was admitted to the facility on [DATE], and had diagnoses including depression (mood disorder characterized by low mood, a feeling of sadness, and a general loss of interest in things). Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) of 11, which indicated that the resident was moderately cognitively impaired.
Observation, on November 3, 2024, at 12:35 p.m. revealed that Resident R129 had two containers of a nutritional health shake and four cups of yogurt on his bedside counter. The food items were at room temperature and their labels indicated that they required refrigeration. Interview, at the time of the observation, Resident R129 stated that he keeps these foods in his room for days at a time, refused to discard them and insisted that they do not spoil or go bad at room temperature.
Continued observation, on November 4, 2024, at 9:51 a.m. revealed that Resident R129 had several additional containers of nutritional health shake and cups of yogurt on his bedside counter.
Further observation, on November 5, 2024, at 10:13 a.m. revealed that Resident R129 continued to have several cups of yogurt on his bedside counter.
Review of Resident R129's care plan, dated initiated January 9, 2024, revealed that the resident had a behavior problem related to hoarding food and milk. Listed interventions included to anticipate the resident's needs and educate the resident regarding the potential hazards of hoarding food. No other interventions were listed to address the resident's hoarding behaviors.
Interview on November 3, 2024, at 12:39 p.m. Employee E25, licensed nurse, confirmed that nursing staff are aware that Resident R129 has hoarding behaviors including keeping dairy products at room temperature in his room, and that due to this the foods are unsafe to consume. Employee E25, licensed nurse, stated that Resident R129 will not allow staff to remove the food items from his room and that nursing staff don't know what else to do to manage the resident's hoarding behaviors.
Observation on Resident R117 conducted on November 3, 2024, at 12:51 p.m. revealed that Resident R117 was in bed.
Review of Resident R117's clinical record revealed that Resident R117 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction (stroke) due to embolism to the right vertebral artery, aphasia, cerebral atherosclerosis.
Further review of Resident R117's clinical record revealed a physician's diet order dated August 13, 2024 for: Heart Healthy / CCD (controlled carbohydrate diet) / NAS (no added salt) diet Regular - Level 7 texture, Thin consistency.
Review of nutrition assessment dated [DATE] revealed that resident was non-compliant with diet.
Interview with regional dietician Employee E19 conducted on November 6, 2024, at 12:18 p.m. confirmed that Resident R117 was non-compliant with her diet.
Review of Resident R117's care plans revealed that a care plan was not developed for Resident R117's non-compliance with her diet.
Review of Resident R100's annual Minimum Data Set (MDS - federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing facility) completed August 16, 2024, revealed Resident R100 entered the facility on August 28, 2023 with diagnosis' of dementia (progressive degenerative disease of the brain), seizure disorder (neurological disorder that cause brief episodes of spasms, unresponsiveness), and malnutrition.
Review of the resident's care plan dated May 29, 2024, revealed that Resident R100 has activities of daily living (ADL) self-care performance deficit related to Alzheimer's, confusion, dementia, and impaired balance. Interventions include: Resident R100 requires setup and assistance with eating, supervision for eating, and assistance by one for eating staff dated August 4, 2024.
Review of facility's grievances revealed a concern report dated September 6, 2024, related to Resident R100 found with ball of foil in mouth. Resident foil was to be removed from juice cups. They staff were educated not to allow resident to have foil from juice cups for safety and all personal items to be stored out of reach related to dementia and confusion.
Observation of resident room with large sign of the wall stating Do not leave any paper, and do not leave anything disposable in reach of the resident.
Continued review of the resident's care plan revealed that there were no interventions developed in Resident R100's care plan related to staff ensuring that there were no foil from juice cups or paper left in the resident's tray and/or at the reach of the resident.
28 Pa Code 201.18(b)(1) Management
28 Pa Code 211.10(a) Resident care policies
28 Pa Code 211.12(d)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to main...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to maintain effective infection control practices related to barrier precautions and personal protective equipment for three of 32 residents reviewed (Residents R43, R81, and R52) and proper disposal of PPE by staff prior to leaving room for 4 out of 17 rooms observed.
Findings include:
Review of facility policy titled Isolation Steps Categories of Transmission Based Precautions revised August 1, 2023, revealed the facility shall make every effort to use the least restrictive approach to managing individuals with potentially communicable infections enhanced barrier precautions expands the use of PPE (personal protective equipment) beyond situations in which exposure to blood and bodily fluids is anticipated and referred to the use of donning gloves during high contact resident care activities that provide opportunities for the transfer of multi drug resistant organisms (MDRO) to staff hands and clothing. All residents with any of the following conditions should use enhanced barrier precautions infection or colonization with a novel or targeted MDRO when contact precautions do not apply and or open wounds in our dwelling medical devices examples are central line, urinary catheter, feeding tube, and tracheostomy regardless of MDRO colonization status. Examples of infections requiring Enhanced Barrier Precautions, but are not limited to:
MRSA - Methicillin-Resistant Staphylococcus Aureus
VRE - Vancomycin-Resistant Enterococci
CRE - Carbapenem-resistant Enterobacteriaceae
Carbapenem-resistant Pseudomonas
Carbapenem-resistant Acinetobacter baumanni
Candida auris
Multidrug-resistant Pseudomonas aeruginosa
Drug-resistant Streptococcus pneumoniae
GNB - Multidrug-Resistant Gram-Negative Bacilli (also known as Extended Spectrum Beta Lactamase (ESBL) which may include:
o
Escherichia coli (Ecoli)
o
Klebsiella pneumoniae
o
Acinetobacter baumannii
o
Pseudomonas aeruginosa
All residents with any of the following conditions should use enhanced barrier precautions:
Infection or colonization with a novel or targeted MDRO when Contact Precautions do not apply.
Open wounds and/ or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy) regardless of MDRO colonization status who reside on a unit or wing where a resident known to be infected or colonized with a novel or targeted MDRO resides.
Review of facility policy, Administering Medication dated April 17, 2024, revealed, Staff shall follow established facility infection control procedures (e.g., hand washing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications.
Review of physician orders for Resident R43 revealed an order, dated September 13, 2024, which indicated that the resident required Enhance Barrier Precautions due to having an indwelling PEG tube (percutaneous endoscopic gastrostomy - a surgical opening and placement of a tube though a person's abdominal wall into their stomach).
Observation of the morning medication pass on November 3, 2024, at 9:51 a.m. Employee E26, licensed nurse, prepared medications for Resident R43. A sign was posted on Resident R43's door indicating that the resident required Enhanced Barrier Precautions. Employee E26, licensed nurse, crushed Resident R43's medications and administered them via the resident's PEG tube. Throughout the administration of Resident R43's medications, Employee E26, licensed nurse, only wore a pair of gloves. Interview, at the time of the observation, Employee E26, licensed nurse, stated that she didn't know where any other PPE were located.
Observation of the breakfast meal served on the fourth floor nursing unit on November 3, 2024, at 10:58 a.m. revealed that residents were served pancakes with syrup, scrambled eggs, trix cereal, coffee, sugar, nondairy creamer and milk. Continued observation revealed that Employee E29, nurse aide, while assisting a resident with their meal, picked up the resident's pancake with her bare hands and ripped the pancake apart, then placed the pancake pieces back on the resident's plate.
Observation of wound care for Resident R81 on November 3, 2024, at 1:45 p.m. revealed Employees E10 and E12, licensed nurses, perform wound care on the resident's right foot. Employees E10 and E12, licensed nurses, worn gowns and gloves during the procedure. After the treatment was completed, there was no container or place to properly dispose of the used PPE within the vicinity of the resident's room. Employee E12, revealed that the gowns were washable and stated that there was a bin in the resident shower room to put the used gowns in. Employee E12, licensed nurse, then proceeded to walk all the way down the hall to the resident shower room. Observation of the resident shower room with Employee E12, licensed nurse, revealed that there was no designated container for used gowns; Employee E12, licensed nurse, obtained a trash bag and placed the used gowns in it.
Observation conducted on November 4, 2024, at 10:22 am during a follow-up observation of the second-floor unit revealed that there were no bins to discard used PPE's (protective personal equipment) in room [ROOM NUMBER] observation of the second-floor hallway conducted on November 4, 2024 at 11:40 AM revealed that there was no bin outside the resident's room to discard used PPE's (protective personal equipment).
Interview with Nurse aide, Employee E17 conducted at the time of the observation revealed that after taking care of residents who are on ABP (enhanced barrier precaution), she takes the used PPE out of the room and take them in the soiled utility room where they throw it on the bin.
Follow-up observation of the second floor conducted on November 5, 2024, at 11:03 am with Employee E18 revealed that room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] had Enhanced Barrier Precaution signage posted outside the rooms. Observation of room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] revealed that there were no bins to discard used PPEs inside room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER].
Interview with licensed nurse, Employee E18 conducted at the time of the observation revealed that staff must wear PPE's before entering room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] due to the facility's Enhanced Barrier Precaution policy. Further, Employee E18 confirmed that room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER] did not have bins to discard used PPE.
Interview with DON Employee E2 conducted on November 5, 2024 at 10:10 am revealed that there should be bins in the resident's rooms with enhanced barrier precaution for staff to discard their PPE's prior to leaving the room.
Observations conducted on November 3, 2024, time on the third-floor nursing unit revealed signs posted on the door or wall outside the resident rooms indicating a high contact resident care activities that require use of gown and gloves.
Observations conducted on November 3, 2024, at 1:15 p.m. the third-floor nursing unit revealed no PPE stationed on the floor for access to use. This observation confirmed by Employee E12 Interview with unit manager confirmed that there was no PPE on the floor.
Observation of Resident R52's door revealed a sign on the door stating the resident in the room is on enhanced barrier precautions.
Review of Resident 52's quarterly Minimum Data Set (MDS - federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing facility) dated October 1, 2024 revealed that Resident R52 was admitted into the facility April 6, 2022 with diagnoses of respiratory failure (condition which results from inadequate gas exchange)and Crohn's disease (an inflammatory bowel disease). Resident required a colostomy bag (a surgical procedure that creates an opening in the abdominal wall, to allow waste to exit the body) and a tracheostomy (a surgical procedure that create an opening in the neck and trachea to help a person breath).
Observation of Resident R52 on November 3, 2024, at 1:07 p.m. revealed Nurse aide, Employee E11 and Nurse aide, Employee E16 providing colostomy care to Resident R52. Further observation revealed that Employee E11 and Employee E16 were not wearing proper PPE, only gloves. Interview with Employee E11 at time of observation, revealed that she did to need to wear PPE.
Interview with Licensed nurse unit manager, Employee E12 confirmed that there was no PPE on the floor.
Interview with Licenses nurse, Employee E10 during the above observation, when questioned how she administered medications to the residents on the floor that were ordered tube feeding, Employee E10 confirmed that she did not wear any PPE.
Observation on November 5, 2024 at 10:28 a.m. of Licensed nurse, Employee E25 on providing care to Resident R52, revealed that Licensed nurse Employee E25 was not practicing proper infection control by not adhering to wearing required PPE.
Interview with Licensed nurse, Employee E25 at time of observation, she believed that the PPE was only for toileting the resident.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional st...
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Based on observations, review of facility policies and interviews with staff, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.
Findings include:
An initial tour of the main kitchen on November 3, 2024, at 9:45 a.m. with the Food Service Director, Employee E4, revealed the following:
Observations revealed boxes of dry cereal placed directly on floor next to tray line while waiting for service to start.
Observations in the freezer revealed a tray of premade meatballs that was not sealed, raw burger patties on the shelf not in any packaging, waffles not in their original packaging with no date, open vegetable blend with no date.
Observations revealed an industrial fan facing the dish machine where clean dishes come out with a thick layer of dust build-up on the fan.
Observations revealed a small red bucket with dirty water/cleanser and a cloth on the shelf beneath the coffee maker.
Observations in the dry storage room revealed a plastic bin filled with condiment packets and a red liquid build-up in the bottom of the bin. Further observations revealed an open bag of grits with no date and was not sealed shut.
Observations of the cooking equipment such as the fryer, stove, and tilt skillet, revealed they were dirty with significant grease build up on the front of the equipment.
Observations behind the ice machine revealed a pool of water on the floor with fruit flies present around the ice machine. Interview with the Food Service Director, Employee E4, revealed the floor drain backs up causing an overflow of water onto the floor.
Observations of the three-compartment prep sink revealed a black bin with water pooled at the bottom and shelf stable milks in the bin. Fruit flies were observed hovering the bin.
The above observations were confirmed on November 3, 2024, by the Food Service Director, Employee E4, throughout the duration of the tour.
Interview on November 6, 2024, at 12:05 p.m. with the Food Service Director, Employee E4, revealed the dishwasher becomes backed up due to a plumbing issue, causing water to pour out from underneath the dishwasher and onto the floor, subsequently causing the floor to become flooded with inches of water during use of the dishwasher. Further interview and observations also revealed the sink in the dishwasher area has a large crack in it, causing water to leak and further contributing to a flooded floor.
Observation, on November 3, 2024, at 12:35 p.m. revealed that Resident R129 had two containers of a nutritional health shake and four cups of yogurt on his bedside counter. The food items were at room temperature and their labels indicated that they required refrigeration. Interview, at the time of the observation, Resident R129 stated that he keeps these foods in his room for days at a time, refused to discard them and insisted that they do not spoil or go bad at room temperature.
Continued observation, on November 4, 2024, at 9:51 a.m. revealed that Resident R129 had several additional containers of nutritional health shake and cups of yogurt on his bedside counter.
Further observation, on November 5, 2024, at 10:13 a.m. Revealed that Resident R129 continued to have several cups of yogurt on his bedside counter.
Interview on November 3, 2024, at 12:39 p.m. Employee E25, licensed nurse, confirmed that nursing staff are aware that Resident R129 has hoarding behaviors including keeping dairy products at room temperature in his room, and that due to this the foods are unsafe to consume.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa.Code 201.18(b)(3) Management
Sept 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
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observations, review of facility menus and interviews with residents and staff, it was determined that the facility failed to ensure that menus were posted and followed as required on one of ...
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Based on observations, review of facility menus and interviews with residents and staff, it was determined that the facility failed to ensure that menus were posted and followed as required on one of four floors observed (third floor).
Findings include:
Interview on September 12, 2024, at 10: 28 a.m. Resident R2 stated that food is cold, food ticket is blank, and resident don't offer food choices per resident's preferences. Menus were not posted or provided to residents.
Interview on September 12, 2024, at 10: 35 a.m. Resident R3 stated no menu provided to residents who are bedbound, and food is disgusting and gross. Never know what you going to get, not following the resident food ticket.
Interview on September 12, 2024, at 10: 30 a.m. Resident R1 stated that resident don't offer food choices per resident's preferences.
Interview on September 12, 2024, at 10:54 a.m. with Assistant Director of Nursing Employee E2, confirmed that menus are only posted in the nursing station and not sure how bedbound residents know what's on the menus.
Observation on the third-floor nursing unit on September 12, 2024, at 11:40 a.m. revealed that the menus was posted at the nursing station only.
Observation in the Kitchen on September 12, 2024, at 11:55 a.m. Director of Service, Employee E3 confirmed that no menu in resident rooms. It's nurse aide's job to notify bedbound residents, what's on the menu. Also reported that residents' food tickets are blank because meal trucker stopped yesterday due to the new company.
Interview the Nursing Home Administrator Employee E1, on September 12, 2024, at 1:37 p.m. confirmed that residents' food tickets are blank because of the new company and menus are not giving to bedbound residents.
28 Pa Code 211.6(a) Dietary Services
Aug 2024
1 deficiency
1 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
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of facility documentation, review of clinical records, and interviews with residents and staff, it was determined that the facility failed to ensure that the resident environment remained free of accident hazards by failing to monitor the temperature of hot water beverages served to a resident. This failure resulted in actual harm to Resident R1 who spilled a hot water beverage and sustained an abdominal and chest burn injury, for one of five residents reviewed. (Resident R1)
Findings include:
Review of facility policy on Hot Liquid with a most recent revision date of January 17, 2019, revealed that under section Policy: Residents will be served coffee, hot water, soup, or any hot liquid at a palatable temperature that will not burn the skin. Under section Purpose: To ensure residents are served coffee, hot water, soup, or any liquid that will not burn the skin if spilled on a resident. Under section Guidelines: #1. Coffee will be brewed at recommended and soup will be cooked to appropriate temperature. #2 Coffee, hot water, soup or any hot liquid is to leave kitchen at a range of 140 to 168°. #3 Coffee, hot water, soup, or any hot liquid temperature at point of service should be at or below 145°. #4. If coffee, hot water, soup, or any hot beverage is served to resident at a different time other than at meals, temperature should be taken before service and not served above 145°F.
Review of Resident R1's clinical record revealed that Resident R1 was admitted to the facility on [DATE], with diagnoses of CVA (cerebrovascular accident) with right sided weakness, Bipolar disorder, and COPD (chronic obstructive pulmonary disease)
Review of Resident R1's quarterly Minimum Data Set (MDS- assessment of resident needs) dated May 29, 2024, revealed a BIMS (brief interview for mental status) score of 15 suggesting that Resident R1 was cognitively intact.
Review of Resident R1's care plans revealed that the resident was care planned for impairment related to safety awareness, reduced independence with activities of daily living, and difficulty navigating the SNF (skilled nursing facility) environment. Resident R1 has impaired cognitive function/dementia or impaired thought processes related to Dementia.
Continued review of the resident's care plan revealed a care plan developed on August 11, 2024 related to a 2nd degree burn to resident's right upper quadrant and right breast. Interventions included to keep area clean and dry, assistance with handling all meals trays and treatments done as ordered.
Review of Resident R1's nursing note dated July 29, 2024, time stamped 2:58 p.m. revealed that Resident R1 was brought to the 3rd floor and stated she spilled hot water on herself in the main dining room. RUQ (right upper quadrant) abdomen and R (right) breast noted with redness. Resident stated she was holding tray and spilled hot water on herself. A&D applied to area; pain medication offered resident denied. MD (physician) notified, to monitor area q (every) shift.
Review of Resident R1's wound progress notes dated August 8, 2024, revealed that Resident R1 was seen by wound care for an assessment and treatment recommendation for a burn secondary to hot water on right breast, RLQ (right lower quadrant)/RUQ (right upper quadrant) ABD (abdominal). Wounds present < 1 week. Patient initially had pain, now improved. No s/s (sign/symptom) of infection. Right breast burn: 1.8 x 0.8 x 0.05 centimeters, right abdominal burn: 8 x 8 x 0 centimeters.
Interview with Resident R1 conducted on August 14, 2024, at 12:07 p.m revealed that she forgot the date of the incident but on the day of the incident, she requested to have lunch in the main dining room on the first floor. Resident R1 revealed that she asked Dietary aide, Employee E4 to bring her lunch to the dining room. Resident R1 further revealed that she was in the lobby area in front of the front desk waiting for Employee E4 to bring her lunch. When employee E4 brought her lunch in a tray.
Resident R1 alleged that she asked Dietary aide, Employee E4 to bring the tray to the dining room but Dietary aide, Employee E4 refused to bring the tray to the dining room stating that she didn't have time to do it. The resident then carried the tray herself while propelling herself with her feet on the wheelchair. Further, Resident R1 also alleged that she asked Dietary aide, Employee E4 to take the hot water out of the tray but Dietary aide, Employee E4 left it on the tray. Resident R1 then carried tray and spilled the cup of hot water on herself on her way to the dining room which caused her to get burned on her chest.
Interview with Dietary aide, Employee E4 conducted on August 14, 2024, at 1:13 p.m. revealed that when preparing the food trays that go to the unit, she puts the food together according to the menu. Coffee and hot water is poured, then it goes in the truck, goes upstairs then nurse aides served the tray. Further Dietary aide, Employee E4 revealed that she was never assigned to check the temperature.
Continued interview with Dietary aide, Employee E4 revealed that Resident R1 normally eats in Main Dining Room on the first floor but that day she wanted to eat upstairs. However, Resident R1 changed her mind and decided to eat in the main dining room. Lunch service was already finished at the time, so Resident R1 requested for a special lunch tray. Employee E4 also revealed that she had to prepare a special tray for Resident R1.
Further interview with Dietary aide, Employee E4 confirmed that she did not check the temperature of the food that she prepared for Resident R1. Employee E4 revealed that when she took Resident R1's tray out of the kitchen, resident was in the lobby at the front desk and that she handed the tray to Resident R1, the resident took the tray from her hand. Dietary aide, Employee E4 revealed that the front desk Receptionist, Employee E8 and Social Worker, Employee E6 were near the front desk. Social Worker, Employee E6 offered to take the tray from Resident R1 and offered to carry it to the dining room but Resident R1 refused. Social Worker, Employee E6 attempted to take the tray from Resident R1 but resident refused. Employee E4 further revealed that when she left Resident R1 was still in front of the front desk and that she was not aware the resident had burned herself until later.
Interview with Director of Dietary, Employee E3 conducted on August 14, 2024, at 1:26 p.m. confirmed that Dietary aide, Employee E4 did not check the water temperature before taking the tray to Resident R1. Employee E3 stated that the cooks conduct a random food temperature check during tray line and performs a random check the coffee and water temperatures upon poring and then 15 minutes later.
Interview with Social Worker, Employee E6 conducted on August 14, 2024, at 1:37 pm revealed that she was in the lobby at the time of the incident. Social Worker, Employee E6 revealed that she saw Dietary Aide, Employee E4 coming out from the kitchen area and Resident R1 was sitting at the front desk. Employee E6 revealed that she saw Dietary aide, Employee E4 handed Resident R1 a lunch tray. Employee E6 also revealed that she asked Resident R1 if she can carry the tray for her and that Dietary aide, Employee E4 then also offered to take tray for Resident R1, but Resident R1 insisted that she can do it. Employee E6 revealed that she left after and did not see the incident and did not know where it happened. She found out about it later.
Interview with front desk Receptionist, Employee E8 conducted on August 14, 2024, at 12:18 p.m. revealed that he was manning the front desk at the time of the incident. Receptionist, Employee E8 revealed that he saw Dietary aide, Employee E4 give Resident R1 something but didn't know what it was and that he was busy doing something else at the time.
Interview with Recreation aide, Employee E7 conducted on August 14, 2024, at 1:44 p.m. revealed that on July 29, 2024 she was going through dining room and saw Resident R1 outside the dining room in the lobby area and she had a tray on lap and the tray had food on it, asked if she needed help and she refused. Stated I got it. Recreation aide, Employee E7 then proceeded to go into the dining room and left Resident R1 outside the dining room area.
Review of cooling/heating log for July 28, 2024, to August 10, 2024, revealed that coffee temperature was checked every day for starting temp and 15 minutes after every day for breakfast, lunch, and dinner
Review of security camera located in the lobby area revealed that the camera orientation was facing the entrance of the lobby and shows one of the doorways leading to the kitchen. Further review of the lobby security camera revealed that at 1:56 p.m. resident was seen wheeling herself to the front desk and stayed in front of the front desk. At 1:58 p.m Dietary aide, Employee E4 was seen walking out of the kitchen door with a tray in her hands. Dietary aide, Employee E4 approached the front desk and handed the tray to resident. Social Worker, Employee E6 was seen approaching Resident R1 and what appears to be a verbal interaction between Resident R1 and Social Worker, Employee E6 occurred. Dietary aide, Employee E4 and Social Worker, Employee E6 was then seen walking away from the Resident R1 and Resident R1 wheeled herself towards the direction of the entrance to the dining room door. There was no video coverage for area leading towards the dining room.
The facility failed to test the temperature of a hot water beverage prior to providing it to Resident R1. This failure resulted in actual harm to Resident R1 who spilled the hot water beverage and sustained a second degree abdominal and chest burn.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.6(c)(d) Dietary Services
Apr 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 F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility policy and interviews with residents and staff, it was determi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, review of facility policy and interviews with residents and staff, it was determined that the facility failed to provide assistance with showers for one of eight residents reviewed (Residents R4).
Findings include:
Review of facility policy, ADL (Activities of Daily Living) Policy, dated December 4, 2023, indicated that the facility will provide care and services for the following activities of daily living: including Hygiene- bathing, dressing, grooming, and oral care. Further review revealed that a resident who is unable to carry out activities of daily living will receive the necessary services to maintain goof nutrition, grooming, and personal and oral hygiene.
Interview with Resident R4, on April 17, 2024, at 11:27 a.m. revealed that the resident had not received a shower for the last three weeks. Resident R4 stated I did not know I can receive a shower with my condition and that he was never offered a shower.
Review of R4's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses including reduced mobility, need for assistance with personal care, and spinal stenosis (stiffness and severe back pain).
Review of Resident R4's care plan, date-initiated March 29, 2024, revealed that Resident R4 has an ADL selfcare performance deficit, and requires assistance by one staff with personal hygiene.
Further review of resident's physician orders revealed an order dated, April 2, 2024, for bath/shower twice weekly every dayshift on Wednesday and Saturday.
Review of Resident R4's ADL's task documentation which stated the following instructions: Specify- type of bath, days of the week ad shift of bath. Revealed that the resident had received a bed bath on the following days: 3/29, 4/3, 4/4, 4/5, 4/6, 4/8/, 4/10, 4/13. Further review failed to reveal documentation that Resident R4 was offered or received a shower.
Interview with Nurse Aide, Employee E4, who was providing direct care to Resident R4, was conducted on April 17, 2024, at 1:00 p.m. Employee E4 confirmed that there was no documentation of resident shower refusals, and that the resident was only assisted with a bed bath.
Interview with the Nursing Home Administrator on April 17, 2024, at 1:47 p.m. confirmed that there was no documentation in the clinical records of the reason as to why Resident R4 was not provided assistance with showers on the days noted above and or resident shower refusals. Further interview confirmed there was no evidence of meetings with the interdisciplinary team and resident representative to ascertain the reasons why the resident was refusing care; no alternative interventions were offered.
28 Pa Code 211.12(d)(5) Nursing services
Jan 2024
9 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policies, facility documentation and interviews with staff, it was determined that the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility policies, facility documentation and interviews with staff, it was determined that the facility failed to ensure that water temperatures in resident bathroom hand sinks and shower rooms were maintained at a safe temperature for three of three nursing units (Second, Third and Fourth Floor Nursing Units). This failure placed residents on the (Second, Third and Fourth Floor Nursing Units) at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation. (Second, Third and Fourth Floor Nursing Units).
Findings Include:
Review of facility policy titled, Water Temperature with a revision date of November 24, 2024 revealed The facility should insure that plumbing fixtures that supply hot water and are accessible to the residents shall be thermostatically controlled so the water temperature at the fixture does not exceed one hundred ten degrees Fahrenheit.
Observation conducted on January 9, 2024 at 10:30 a.m. in Resident R132's hand sink revealed that the hot water felt uncomfortably too hot to the touch. The Director of Maintenance, Employee E3 was called to Resident R132's room to take the temperature of the water at the hand sink. The temperature of the water measured 129 degrees Fahrenheit.
Observation and testing of the hot water was completed on the Second floor. The testing was made with Director of Maintenance Employee E3 at 11:15 a.m. on January 9, 2024. The following hot water temperatures were found to be above safe hot water temperature:
Shower room hand sink measured at 129 degrees Fahrenheit.
room [ROOM NUMBER] measured at 129 degrees Fahrenheit.
room [ROOM NUMBER] measured at 142 degrees Fahrenheit.
room [ROOM NUMBER] measured at 122.6 degrees Fahrenheit.
room [ROOM NUMBER] measured at 124.4 degrees Fahrenheit.
room [ROOM NUMBER] measured at 124 degrees Fahrenheit.
room [ROOM NUMBER] measured at 123 degrees Fahrenheit.
On January 9, 2024 at 12:02 p.m. observation was made of the boiler room with the Director of Maintenance Employee E3. The thermometer from the valve to the resident's rooms was reading 125 degrees Fahrenheit. When asked what it was supposed to be set at the Director of Maintenance replied 110 degrees Fahrenheit. When asked if anyone checks the temperatures regularly, Employee E3 stated that it was checked each morning Monday through Friday. When asked how often the Director of Maintenance, Employee E3 had to adjust the flow of the hot/cold water to the mixing valve he replied, daily. When asked who usually brings it to his attention Employee E3, replied the nurses let me know if it is too hot or too cold.
On January 9, 2024 at 12:18 p.m. Director of Maintenance, Employee E3 stated he has the cold set up as much as possible, and as it goes on more in the day the water will be cooled down. He stated that he has had to continue to adjust the water temperatures at the facility daily.
On January 9, 2024 at 12:20 p.m. additonal water temperatures were taken with Director of Maintenance, Employee E3 on the second floor. The following hot water temperatures were found to be above 110 degrees:
room [ROOM NUMBER] measured at 127.7 degrees Fahrenheit.
room [ROOM NUMBER] measured at 144 degrees Fahrenheit.
room [ROOM NUMBER] measured at 117.5 degrees Fahrenheit.
room [ROOM NUMBER] measured at 115.8 degrees Fahrenheit.
Observation and testing of the water on the Third floor were made on January 9, 2024 at approximately 12:28 p.m.
Hand sink #1 in shower room measured at 145 degrees Fahrenheit.
Hand sink #2 in shower room measured at 156 degrees Fahrenheit.
Shower room [ROOM NUMBER] measured at 180 degrees Fahrenheit.
Shower room [ROOM NUMBER] measured at 145 degrees Fahrenheit.
room [ROOM NUMBER] measured at 155 degrees Fahrenheit.
room [ROOM NUMBER] measured at 150 degrees Fahrenheit.
room [ROOM NUMBER] measured at 150- degrees Fahrenheit.
room [ROOM NUMBER] measured at 155 degrees Fahrenheit.
Observation and testing of the water on the Fourth floor were made on January 9, 2024 at approximatley 12:28 p.m.
Shower room [ROOM NUMBER] was 132 degrees Fahrenheit.
Shower room [ROOM NUMBER] was 124.7 degrees Fahrenheit.
room [ROOM NUMBER] measured at 122 degrees Fahrenheit.
Rooms 428 measured at 138 degrees Fahrenheit.
Rooms 422 measured at 135 degrees Fahrenheit.
Further observations of the shower roomsat the time the water temperatures were taken revealed the following:
The second floor shower room had no thermometers in Shower room [ROOM NUMBER].
The Third floor had no thermometers in either of the shower rooms (Shower room [ROOM NUMBER] or Shower room [ROOM NUMBER]).
The fourth floor had a hanging thermometer that only went up to 105 degrees Fahrenheit.
Interview held with Nurse Aide, Employee E32 at 12:45 p.m stated that there are thermometers hanging in the shower room that we use to check the water. I aim for 95-96 degrees. Anything over 100 I consider too hot. If the water is too hot, I shut it off, remove the resident from the shower room and inform the nurse.
Interview held with Nurse aide, Employee E30 on January 9, 2024 at 1:33 p.m. revealed it was her first day back to work and she did not know about the showers or how to test the water.
Interview held with Nurse aide, Employee E31 on January 9, 2024 at 1:35 p.m. revealed she was an aide and when asked about checking the temperature of the shower water Employee E31 stated that she tests the water out on herself and then adjusts the hot water. She also stated that the resident will also tell us if it's too hot or cold if they are oriented.
Interview held with Licensed nurse, Employee E22 on January 9, 2024 at approximately 12:35 p.m. revealed that she complained a few days ago to the maintenance department that the water was too cool in room [ROOM NUMBER] and in the nurses' breakroom.
Interview held with Nurse aide, Employee E33 on January 9, 2024 at approximately 12:39 p.m. revealed that she thought between 100 to 120 degrees Fahrenheit was the safe range, they had no complaints about the water and all residents had a bed bath today. Employee E33 stated they use the thermometer to test the water.
Interview held with Nurse aide, Employee E13 revealed that she works as unit clerk and also works the 3-11 shift. Employee E13 stated that she did not know the correct temperatures. Employee E13 stated they always mix the hot and the cold and puts her hand underneath to test.
Based on the above findings Immediate Jeopardy to the safety of the residents was identified to the Nursing Home Administrator on January 9, 2024 at 2:05 p.m. for failure to ensure that safe hot water temperatures were maintained on the Second, Third and Forth Floor Nursing units. The Nursing Home Administrator was provided with the Immediate Jeopardy template on January 9, 2024 at 2:09 p.m. and an immediate action plan was requested.
The following action plan was received and accepted on January 9, 2024 at 5:23 p.m.
-Immediately shut down the hot water system- completed 1/9/24
-Notified the administrator- completed 1/9/24
-Notified staff that residents should not use the hot water- completed 1/9/24
-Notified residents to not use the hot water- completed 1/9/24
-Notified the vendor of hot water system issue, vendor on site, assessed issue. Repairs in progress, Plan is to have repair completed by 1/9/24.
-Audits initiated to ensure residents are not using the hot water- completed 1/9/24
-Immediately initiated education for staff prior to the start of the next shift that water temperatures should not exceed 110 degrees-80% completed 1/9/24 100% completed 1/10/24
-Ensure thermometers are available on the units and in showers rooms- completed 1/9/24
-If water temperatures are found to be 100 degrees the hot water will be shut off, administration will be notified.
-Wipes will be provided for all care during the hot water repair.
-Water temperature policy was updated to ensure safe processes for monitoring water temperatures- completed 1/9/24
-Facility staff education prior to the start of the next shift on the revised water temperature policy and appropriate water testing methods 80% completed 1/9/2024, 100% completed 1/10/2024
-Maintenance director of designee will audit water temperatures every two hours for three days in two random areas on each of the three resident room floors.
-Maintenance director or designee will audit water temperatures three times a day for three days.
-Maintenance director or designee will audit water temperatures twice a day for three days.
-Maintenance director or designee will audit water temperatures daily ongoing
A review of water temperature audits was completed on January 10, 2024. Hot water temperatures were found not to exceed 110 degrees.
Interviews were conducted on January 10, 2024, between 9:15 a.m. and 9:40 a.m., with facilty staff revealed that they were able to verify the implementation of the immediate action plan. Nursing staff were able to verbalize to facility's updated policy, including that water temperatures should not exceed 110 degrees Fahrenheit, what to do if water temperatures were found to be too hot, how is the temperature of the water tested, if a therometer was not available where can a thermometer be found and who to notify if the temperature of the hot water was found over 110 degrees Fahrenheit.
The hot water at residents' hand sinks and shower rooms on the Second, Third and Fourth Floor were tested and verified that they did not exceed 110 degrees Fahrenheit. Water temperature logs were reviewed and revealed appropriate water temperatures.
Following verification of the implementation of the immediate action plan, review of water temperature logs and review of staff education documentation, the Immediate Jeopardy was lifted on January 10, 2024 at 3:52 p.m.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(1) Management
28 Pa Code 201.18(b)(3) Management
28 Pa Code 205.63(c) Plumbing and piping systems required for existing and new construction
28 Pa Code 211.12(d)(5) Nursing services
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 observations of care and services, reviews of policies and procedures, interviews with residents, clinical record reviews and interviews with staff, it was determined that the facility failed...
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Based on observations of care and services, reviews of policies and procedures, interviews with residents, clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that each resident's needs and preferences were reasonably accommodated to create an individualized home-like environment for one of six residents reviewed. (Resident R143).
Findings include:
A review of the facility policy titled Activities of Daily Living dated April 1, 2022 revealed that the facility staff was responsible for creating and sustaining an environment that humanizes and individualizes each resident's quality of life. The policy said that the care and services provided by staff were to be person-centered and honor and support each resident's preferences, choices, values and beliefs.
Observations of Resident R143 at 9:30 a.m., on Janaury 9, 2024 revealed that this resident was dressed in soiled sweat pants and shirt. The clothing was visibly soiled with food spillage and bodily fluids.
Observations of Resident R143 at 11:00 a.m., on Janaury 10, 2024 revealed that this resident was wearing the same soiled sweat shirt pajama bottoms and heaviliy soiled loafers.
The comprehensive quarterly assessment (MDS- an assessment of care needs) dated October 12, 2023 indicated that Resident R143 was alert and oriented. The assessment also indicated that this resident was ambulatory, and able to dress and apply footwear to himself independently.
Interview with Resident R143 at 9:30 a.m., on January 9, 2024 revealed that this resident had no clean clothing. The resident also reported that he had very little personal belongings. Resident R143 indicated that he preferred a fitting pair of sneakers.
Observations of the closet and bureau inside Resident R143's room revealed a lack of reasonable accommodations for personal clothing and footwear.
Further interview with Resident R143 revealed that he was unaware that the facility had a personal washer and dryer, located on the ground floor of the facility that was for resident use.
Interview with the Licensed nurse, Employee E10 at 1:00 p.m., on January 9, 2024 confirmed the lack of clean personal clothing and shoes for Resident R143.
28 PA. Code 211.11(a)(c)(d) Resident care policies
28 PA. Code 201.29(4) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observations of care and services, clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to implement a plan of car...
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Based on observations of care and services, clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the facility failed to implement a plan of care to address the dementia needs of one of 32 residents reviewed. (Resident R96 )
Findings include:
A review of the policy titled Comprehensive Care Plan dated April 1, 2022 revealed that it was the responsibility of the facility to develop and implement a comprehensive person-centered care plan for each resident that meets professional standards for quality of care. The policy also said that the care plan would be consistent with resident rights, and include measurable goals, objectives and timeframes for meeting the goals. Care plan are to be implemented to meet each resident's medical, nursing, mental and psychosocial needs. The care plan services are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.
Review Resident R96's admission Minimum Data Set (MDS- assessment of resident's care needs) dated July 27, 2023 indicated this resident had a diagnosis of dementia. The assessment indicated that this resident had cognitive impairment, and was able to ambulate ten to fifty feet with staff supervision or touching assistance.
Observations made with Licensed nurse, Employee E10 of Resident R96 at 9:45 a.m., on Janaury 9, 2024 revealed that this resident was lying in a lateral recumbent position in bed, grasping the over bed table and consistently yelling out.
Observations throughout the day shift on Janaury 9 and 10, 2024 revealed that Resident R96 was not involved in any one to one or small group activities on the Fourth floor nursing unit to address his dementia care needs. Employee E10 reported during this interview that Resident R96 would benefit from a food related activities progam; since he does like to eat snacks.
Clinical record review revealed on January 9, 2024 the psychiatric nurse practitioner confirmed in a progress note that Resident 96 had diagnoses of dementia and agitation.
Review of nursing documentation revealed that on January 11, 2024 Resident R96 screamed throughout the entire day.
A review of Resident R96's care plan dated December 28, 2023 revealed that this resident was supposed to attend and engage with small group activities and one to one activities to redirect behavior of agitation. The care plan indicated that Resident R96 liked to listen to music and watch sports events.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on observation, and review of clinical records, it was determined that the faciltiy failed to ensure that range of motion exercises were inititated and that the use of a sit and stand lift was m...
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Based on observation, and review of clinical records, it was determined that the faciltiy failed to ensure that range of motion exercises were inititated and that the use of a sit and stand lift was maintained for one of two residents reviewed (Resident R70)
Findings include:
Review of Resident R70's quarterly Minimun Data Set (MDS-an assessment of care needs) dated October 28, 2023 indicated that the resident was cognitively intact. The resident had functional impairement on one side of the upper body and that the lower body had no functional impairments. This assessment revealed that the resident could wheel 50 feet with staff supervision and touch assistance.
Review of physical therapy note dated December 1, 2023 indicated that Resident R70 was able to sit to stand/stand to sit transfers with a front wheeled walker.
Clinical record review revealed an occupational therapy progress note dated December 5, 2024 indicated that Resident R70 had the ability improve his left hand grip and strength with the use of nine pound weights, provided with supervision and assist of care giver.
Observations of Resident R70 on Janaury 10, 2024 revealed that nursing staff were transporting the resident in his wheeelchair to the main dining room on the ground floor of the facility.
Interview at 11:00 a.m., on January 9, 2024 with a licensed practical nurse, Employee E10, that was familiar with the care of Resident R70 revealed that resident had the ability to sit to stand/ stand to sit with staff supervision; however staff was not using the sit to stand lift with this resident.
Interview with Resident R70 at 11:30 a.m., on January 9, 2024 revealed that the resident was interested in participation in a exercises and stretching of the upper and lower extremities.
Interview with the director of nursing, Employee E2 at 10:45 a.m., on January 12, 2024 confirmed that the facility had not developed and implemented a care plan for Resident R70 to ensure his needs for range of motion and passive range of motion were maintained or improved.
28 Pa Code 211.10 (c) Resident care policies
28 Pa. Code 211,12(d)(1)(3) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observations, review of facility policy, interviews with staff, and review of facility documentation, it was determined the facility failed to ensure that weights were monitored for three of ...
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Based on observations, review of facility policy, interviews with staff, and review of facility documentation, it was determined the facility failed to ensure that weights were monitored for three of 32 residents reviewed (R36, R97, R106)
Findings Include:
Review of Weight Assessment and Intervention Policy dated February 15, 2020 states, The nursing staff and the Dietician will cooperate to prevent, monitor, and intervene for undesirable weight loss for our residents.
Further review of the facility policy states, 4. The Dietician will also review monthly weights to follow individual weight trends over time. Negative trends will be assessed and addressed by the Dietician whether or not the definition of Significant Weight Change is met.
Review of Resident R36's Minimum Data Set(MDS- assessment of resident's care needs) revealed an admission date of February 22, 2021. The resident had the diagnoses of Anemia, Mild protein-calorie malnutrition, and muscle wasting and atrophy.
Review of Resident R36's weight records revealed that the last weight was taken on November 2, 2023. Review of progress notes revealed no notes attempting to weigh the resident for the month of December. Review of weight book on the unit revealed no (R) for refusal documented for the month of December 2023.
Review of Resident R97's MDS revealed an admission date of February 1, 2023. The resident had a diagnosis of Dysphagia, Nutritional Anemia, Muscle Wasting and Atrophy and Hyperlipidemia.
Review of Resident R97's weight record revealed a -7.93 weight loss over a period of 3 months.
Review of Resident R97's physician orders revealed an order for weekly weights for four weeks every Friday starting on December 22, 2023. Review of weight records revealed no documented weight obtained on December 29, 2024.
Review of Resident R106's MDS revealed an admission date of July 27, 2022. The resident had diagnoses of Hyperlipidemia and Gastroesophageal Reflux Disease.
Review of Nutrition Assessment for Resident R106 completed on December 4, 2023 under Evaluation/Monitoring revealed, What to monitor: Weekly Weights, Nutrition Related biometrics, percentages of meal trays and oral nutrition supplements consumed.
Review of Resident 106's weight record revealed no weekly weights recorded for the third and fourth weeks in December 2023.
Review of Resident R106's meal intake records revealed the facility had not been documenting the percentages eaten from the meal trays.
Review of Resident R106's snack record revealed no snacks recorded to be given over the last 30 days.
Interview held with Registered Dietician Employee E6 on January 11, 2024 at 2:02 p.m. to discuss monitoring of weights. Interview with Employee E6 revealed weights for the second floor may not have been taken due to the hoyer that records weights was broken. Employee E6 stated that there was an issue with the hoyer battery which took some time to resolve. Employee E6 stated that battery would charge and then as soon as they took one weight it would die again. Employee E6 explained how this may be the cause of weights not being obtain.
28 Pa. Code 211.12 (d)(3) Nursing Services
28 Pa Code 211.12 (d)(5) Nursing Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0790
(Tag F0790)
Could have caused harm · This affected 1 resident
Based on observations, clinical record review and resident interview, it was determined that routine dental care was not provided for one of six residents reviewed with dental, chewing and swallowing ...
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Based on observations, clinical record review and resident interview, it was determined that routine dental care was not provided for one of six residents reviewed with dental, chewing and swallowing needs. (Resident R121)
Findings include:
Clinical record review for Resident R121 revealed comprehensive Minimum Data Set (MDS- assessment of resident's care needs) dated September 28, 2023 that indicated that this resident was cognitively intact.
Review of January 2024 physician orders revealed an ordered for a regular soft bite sized foods with thin liquids.
Observations of Resident R121 at 9:30 a.m., on January 12, 2024 with a nursing assistant, Employee E16, that was familiar with the resident's dental status revealed that this resident had a full oral cavity of teeth.
Interview with Resident R121 at 9:15 a.m., on January 12, 2024 revealed that the resident was interested for the consulting dental group to evaluate her mouth. The resident recalled that it had been awhile since she received a dental hygienist examination and cleaning or dentist evaluation of her oral cavity for cavities or infection.
Clinical record review revealed that Resident R121 had not received routine dental care for the year 2023.
28 Pa. Code 211.15 Dental services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interviews with staff and review of facility policy and procedure, it was determined that the facility did not maintain an effective infection control program related to hand hyg...
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Based on observation, interviews with staff and review of facility policy and procedure, it was determined that the facility did not maintain an effective infection control program related to hand hygiene and medication administration for one resident (Resident R53) of four residents observed and glucometer handling and testing for one resident (Resident R19) of one resident observed.
Findings include:
Review of facility policy, Hand Hygiene, published 12/04/2023, revealed, Purpose: to prevent and to control the spread of infectious disease. When: 1. Employees must perform at least appropriate twenty second hand washing procedures using antimicrobial or non-antimicrobial soap and water under the following conditions. 2. If hands are not visibly dirty or soiled, use an alcohol-based rub for the following situations: a. before direct contact with residents; b. before donning gloves; before preparing or handling medications; g. after the removal of gloves including between glove changes during procedures. 3. The use of gloves does not replace or eliminate the need for handwashing /hand hygiene.
Review of facility policy, Administering Medications, dated April 1, 2022, revealed: Protocol: 14. Staff shall follow established facility infection control procedures (e.g. handwashing, antiseptic technique, gloves, isolation precautions, etc.) when these apply to the administration of medications.
Review of facility policy, Glucometer Handling and Testing, dated April 1, 2022 revealed: Procedure:
All glucometers will be cleaned with EPA registered wipe after each use and/or between residents.
Observation of medication administration on January 12, 2024 at 9:15 a.m. with Employee E9, licensed nurse, revealed Employee E9 placing medication directly into her her bare left palm and dropping medication into a medication cup for Resident R53. Employee E9 confirmed that this was her practice.
Further observation of Employee E9 on January 12, 2024 at 9:30 a.m. revealed Employee E9, preparing medication in the medication cup. Employee E9 also took a pair of gloves, an alcohol swab and a glucometer into the room of Resident R19. Employee E9 administered medication to Resident R19. Employee E9 then donned the gloves and wiped Resident R19's finger with alcohol and used the glucometer to obtain a drop of blood to determine Resident R19's blood sugar level. Employee E9 returned to the medication cart, placed the glucometer in a small basket and removed her gloves. Employee E9 did hand sanitize but did not sanitize the glucometer with an appropriate disinfectant wipe. Employee E9 missed an opportunity to hand sanitize before donning gloves.
28 Pa Code 201.14 (a) Responsibility of licensee
28 Pa Code 211.12 (c) Nursing Services
28 Pa Code 211.12 (d) (1) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations of the operations of the Food and Nutrition Services Department and interviews with staff, it was determined that foods were not being stored, prepared, distributed and served in...
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Based on observations of the operations of the Food and Nutrition Services Department and interviews with staff, it was determined that foods were not being stored, prepared, distributed and served in accordance with professional standards for food service safety.
Findings include:
Observations of the dish room area of the main kitchen at 10:00 a.m., on January 9, 2024, noted dietary staff working to clear soiled food service equipment, after the breakfast meal service, revealed that everyday resident equipment for meal services were not thoroughly cleaned and sanitized.
Dishes (dome lids, meal trays, bowls, cups and mugs) had been serviced by the dish machine or three compartment sink; however the dishes were not clear of debris. Further observations revealed a white film, brown and black staining that was adherent to the dome lids, meal trays, bowls, cups and mugs.
Dietary staff were observed putting the meal trays through the dish machine to clean and sanitize the foodservice equipment. After the wet meal trays were observed being placed one on top of each other on a counter top inside the main kitchen. This was an effective drying method for the meal trays. The dietary staff were practicing wet nesting with the meal trays. The stacking of trays without completely drying them was a practice that promoted lingering moisture and growth of bacteria and germs.
Interview with the Director of Dietary Services, Employee E11 at 10:30 a.m., on Janaury 9, 2024 confirmed that the dietary food service equipment used to serve foods and beverages during meal times for the residents was not effectively and thoroughly cleaned; which was not within professional standards for food service safety.
Interview with the Director of Dietary Services, Employee E11 at 9:30 a.m., on Janaury 10, 2024 confirmed that the stacking of meal trays without completely drying them which was not within professional standards for food service safety.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of facility documentation and interviews with staff, it was determined that the Nursing Home Admi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of facility documentation and interviews with staff, it was determined that the Nursing Home Administrator and the Director of Nursing failed to effectively manage the facility related to hot water temperatures in three of three nursing units (Second, Third and Fourth floor) which resulted in an immediate jeopardy situation.
Findings Include:
Review of the job description for the Nursing Home Administrator (NHA) revealed the Nursing Home Administrator (NHA) assumes full-time administrative authority, responsibility and accountability for the operations and for the financial viability of the nursing facility. Manages facility employees in the provision of care and services rendered in accord with professional standards, and in compliance with state and federal laws and regulations. Collaborates with consultants, contractors, referring physicians, community resources, government agencies and advocacy groups. Implements operational and financial objectives of Management and allocates resources in an efficient and economical manner to attain or maintain the highest practicable physical, mental and psycho-social well-being of each resident.
Observations conducted on January 9, 2024 at 10:30 a.m. revealed that the hot water in Resident R132's hand sink was too hot. Director of Maintenance, Employee E3 was called to Resident R132's room to take the temperature of the hot water at the hand sink. The temperature of the hot water measured at 129 degrees Fahrenheit.
Observation and testing of the hot water were completed on the Second floor, Third and Fourth floor with Director of Maintenance, Employee E3 at 11:15 a.m. on January 9, 2024. The hot water was found to range between 115.8 Fahrenheit to 150 degrees Fahrenheit placing residents at risk for burns.
On January 9, 2024 at 12:02 p.m. observation was made of the boiler room with the Director of Maintenance Employee E3. The thermometer from the valve to the resident's rooms was reading 125 degrees Fahrenheit. When asked what it was supposed to be set at the Director of Maintenance replied 110 degrees Fahrenheit. The Director of Maintenance Employee E3 stated that as soon as it was stated he needed his thermometer he came down and adjusted the cool water flow. When asked what the temperature was before he adjusted it, Employee E3 stated 119 degrees Fahrenheit. When asked if anyone checks the temperatures regularly, Employee E3 stated yes, each morning Monday through Friday. When asked how often the Director of Maintenance Employee E3 had to adjust the flow of the hot/cold water to the mixing valve he replied, daily. When asked who usually brings it to his attention Employee E3, replied the nurses let me know if it is too hot or too cold.
On January 9, 2024 at 12:18 p.m. Director of Maintenance, Employee E3 stated he has the cold set up as much as possible, and as is goes on more in the day the water will be cooled down. He stated that he has had to continue to adjust the water temperatures at the facility daily.
Interview held with Nurse Aide Employee E32 at 12:45 p.m stated that there are thermometers hanging in the shower room that we use to check the water. I aim for 95-96 degrees. Anything over 100 I consider too hot. If the water is too hot, I shut it off, remove the resident from the shower room and inform the nurse.
Interview held with nurse aide, Employee E30 on January 9, 2024 at 1:33 p.m. revealed it was her first day back to work and she does not know about the showers or how to test the water
Interview held with nurse aide, Employee E31 on January 9, 2024 at1:35 p.m. revealed she was an aide and asked about checking the temperature of the shower water she stated that she tests the water out on herself and then adjusts the hot water. She also stated that the resident will also tell us if it's too hot or cold if they are oriented.
Interview held with licensed nurse, Employee E22 said that she complained a few days ago to the maintenance department that the water was too cool in room [ROOM NUMBER] and in the nurses breakroom.
Interview held with Nurse aide, Employee E33 thought between 100 to 120 degrees Fahrenheit was the safe range, they had no complaints about the water and all residents had a bed bath today. Employee E33 stated they use the thermometer to test the water.
Interview held with nurse aide Employee E13 works as unit clerk and does second shift. Employee E13 did second shift last Thursday and did not know the correct temperatures. Employee E13 stated they always mix the hot and the cold and puts her hand underneath to test.
This failure placed residents at risk for serious injury from a burn and resulted in an Immediate Jeopardy situation.
Based on the deficiencies identified in this report the Nursing Home Administrator failed to fulfill essential duties and responsibilities of the position, contributing to the Immediate Jeopardy situations.
Refer F689
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 201.18(d) Management
Oct 2023
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
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with staff and residents and review of facility policy, it was determined that the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with staff and residents and review of facility policy, it was determined that the facility failed to ensure that call bells were with in reach for 17 of 24 residents reviewed. (Resident R1, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, and R24).
Findings include:
The policy of the facility on Call Bells dated, April 1, 2022, states; it is the policy of the facility that all residents always have access to call bells. The call system must be accessible to residents, while in their bed, other sleeping accommodations within the resident's room.
On October 12, 2023, at 1:36 p.m., during observations of the nursing units, it was detected that the call bell was not available for Resident R1, room [ROOM NUMBER]-B, as the call bell was tangled with the adjacent resident-bed. The finding was confirmed with Employee E3, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:05 p.m., it was observed in room [ROOM NUMBER]-B, that the call bell was under the bed, and not accessible for Resident R9. The finding was confirmed with Employee E3, at the time of the finding.
On October 12, 2023, at 2:07 p.m., it was observed in room [ROOM NUMBER]-A, that the call bell was on the floor, and not reachable for Resident R10. The finding was confirmed with Employee E3, at the time of the finding.
On October 12, 2023, at 2:09 p.m., it was observed in room [ROOM NUMBER]-A, that the call bell was under the bed, and not within reach of Resident R11. The finding was confirmed with Employee E6, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:12 p.m., it was observed in room [ROOM NUMBER]-A, that the call bell was on the floor, and not accessible for Resident R12. The finding was confirmed with Employee E6, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:14 p.m., it was observed in room [ROOM NUMBER]-B, that the call bell was under the bed, and not accessible for Resident R13. The finding was confirmed with Employee E6, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:16 p.m., it was observed in room [ROOM NUMBER]-A, that the call bell was on the floor and not available for Resident R14. The finding was confirmed with Employee E6, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:19 p.m., it was observed in room [ROOM NUMBER]-A, that the call bell was on the floor and not available for Resident R15. The finding was confirmed with Employee E10, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:21 p.m., it was observed in room [ROOM NUMBER]-A, in the presence of Employee E8, the Director of Environmental Services revealed that the call bell was under the bed and not accessible for Resident R16. The finding was confirmed with Employee E10, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:24 p.m., it was observed in room [ROOM NUMBER]-B, in the presence of Employee E8, the Director of Environmental Services, revealed that the call bell was under the bed, and not reachable for Resident R17. The finding was confirmed with Employee E10, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:30 p.m., it was observed in room [ROOM NUMBER]-B, in the presence of Employee E8, the Director of Environmental Services, revealed that the call bell was on floor and not available for Resident R18. The finding was confirmed with Employee E10, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:32 p.m., it was observed in room [ROOM NUMBER]-A, in the presence of Employee E8, the Director of Environmental Services, revealed that the call bell was under bed and not available for Resident R19. The finding was confirmed with Employee E10, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:34 p.m., it was observed in room [ROOM NUMBER]-A, in the presence of Employee E8, the Director of Environmental Services, revealed that the call bell was on the floor not available for Resident R20. The finding was confirmed with Employee E10, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:36 p.m., it was observed in room [ROOM NUMBER]-A, in the presence of Employee E8, the Director of Environmental Services, revealed that the call bell was on under the bed, and not available for Resident R21. The finding was confirmed with Employee E10, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:38 p.m., it was observed in room [ROOM NUMBER]-A, in the presence of Employee E8, the Director of Environmental Services, revealed that the call bell was on the floor, and not available for Resident R22. The finding was confirmed with Employee E10, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:41 p.m., it was observed in room [ROOM NUMBER]-B, in the presence of Employee E8, the Director of Environmental Services, revealed that the call bell was away from the bed of the resident, and not available for Resident R23. The finding was confirmed with Employee E10, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:43 p.m., it was observed in room [ROOM NUMBER], in the presence of Employee E8, the Director of Environmental Services, revealed that the call bell was, on the floor, not available for Resident R24. The finding was confirmed with Employee E10, a Licensed Nurse, at the time of the finding.
On October 12, 2023, at 2:47 p.m., during an interview with the Director of Environment Services, Employee E8, and Licensed Nurse, Employee E10, confirmed that the facility failed to make certain resident call bells were in reach for Residents.
28 Pa. Code 211.12(d)(1(5) Nursing services
May 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, it was determined that the facility failed to ensure that devices (heel protector/bootie) were maintain in a clean and sanitary condition for one one resident...
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Based on observation and staff interview, it was determined that the facility failed to ensure that devices (heel protector/bootie) were maintain in a clean and sanitary condition for one one resident observed. (Resident R1)
Finding include:
Wound care observation on Resident R1 conducted on May 31, 2023, at 10:15 a.m. with Licensed nurse, Employee E3 and Wound Care nurse, Employee E4 revealed that resident was in bed awake and alert.
Further observation revealed that resident R1's knees were flexed with resident's heel towards his buttocks and positioned towards his left side. Further, Resident R1 had heel protector (booties, material made of foam and fabric used or relieve minimize pressure on resident's heels/feet while in bed) on both feet.
Further observation revealed a strong odor of urine when Resident R1's sheet was pulled down to expose his feet in preparation for the wound care on his ankles.
Further observation revealed that Resident R1's incontinence brief was dry as well as the blanket, sheets and gown.
Further observation revealed that the mattress Resident R1 was on was made of a non porous material.
During treatment observation Resident R1's heel protectors were removed by Wound Care nurse, Employee E4, the two booties that Resident R1 was wearing had yellow stains and dark brownish and black reddish stain on the booties and on bed protector. Further, the heel protector smelled of urine.
Interview with the Wound Care nurse, Employee E4 and Licensed nurse, Employee E2 confirmed that both booties were dirty and needed to be washed.
28 Pa. Code: 201.18(b)(3) Management
28 Pa. Code: 207.2(a) Administrator's responsibility
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that treatment re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that treatment records were completed for one of one residents reviewed. (Resident R1)
Findings include:
Review of clinical record revealed that Resident R1 was admitted to the facility on [DATE], was discharged to a local hospital on April 19, 2023, and was readmitted to the facility on [DATE].
Review of Resident R1's May 2023 Treatment Administration Record revealed no signature or initials of the licensed staff who administered the following treatment to the resident: Skin Prep Wipes Apply to B/L(bilateral) feet topically every day shift for wound care, clean area, apply skin prep to both feet/toes on May 14, 2023 and May 27, 2023;
Santyl External Ointment 250 UNIT/GM (Collagenase) apply to right ankle topically every dayshift for wound care, on May 19, 23, 24, 27 and 31, 2023; Santyl External Ointment 250 UNIT/GM (Collagenase) apply to Left Bunion topically every d shift for wound care on May 19, 23, 24, 27 and 31, 2023; and Medihoney Wound/Burn Dressing External Gel (Wound Dressings), apply to right ankle topically every day shift for wound care on May 4 and 14, 2023.
Interview with the Nursing Home Administrator conducted on May 31, 2023, at 11:48 p.m. confirmed the missing licensed nurse's signatures.
28 Pa. Code: 211.10(c) Resident care policies
28 Pa. Code: 211.12(c) Nursing services
28 Pa. Code: 211.12(d)(1) Nursing services
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 changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 1 harm violation(s), $106,422 in fines. Review inspection reports carefully.
- • 43 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $106,422 in fines. Extremely high, among the most fined facilities in Pennsylvania. Major compliance failures.
- • Grade F (28/100). Below average facility with significant concerns.
Bottom line: Trust Score of 28/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Maplewood Nursing And Rehab Center's CMS Rating?
CMS assigns MAPLEWOOD NURSING AND REHAB CENTER an overall rating of 3 out of 5 stars, which is considered average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Maplewood Nursing And Rehab Center Staffed?
CMS rates MAPLEWOOD NURSING AND REHAB CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 55%, compared to the Pennsylvania average of 46%. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Maplewood Nursing And Rehab Center?
State health inspectors documented 43 deficiencies at MAPLEWOOD NURSING AND REHAB CENTER during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, and 41 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Maplewood Nursing And Rehab Center?
MAPLEWOOD NURSING AND 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 BEDROCK CARE, a chain that manages multiple nursing homes. With 180 certified beds and approximately 166 residents (about 92% occupancy), it is a mid-sized facility located in PHILADELPHIA, Pennsylvania.
How Does Maplewood Nursing And Rehab Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, MAPLEWOOD NURSING AND REHAB CENTER's overall rating (3 stars) matches the state average, staff turnover (55%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Maplewood Nursing And Rehab Center?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "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?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Maplewood Nursing And Rehab Center Safe?
Based on CMS inspection data, MAPLEWOOD NURSING AND REHAB CENTER has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #1 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 Maplewood Nursing And Rehab Center Stick Around?
MAPLEWOOD NURSING AND REHAB CENTER has a staff turnover rate of 55%, which is 9 percentage points above the Pennsylvania average of 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 Maplewood Nursing And Rehab Center Ever Fined?
MAPLEWOOD NURSING AND REHAB CENTER has been fined $106,422 across 3 penalty actions. This is 3.1x the Pennsylvania average of $34,143. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Maplewood Nursing And Rehab Center on Any Federal Watch List?
MAPLEWOOD NURSING AND 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.