RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER
For profit - Corporation
120 Beds
PARAMOUNT CARE CENTERS
Data: November 2025
Trust Grade
60/100
#222 of 653 in PA
Photo by Pinny L.
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
River's Edge Rehabilitation & Healthcare Center has a Trust Grade of C+, indicating that it is slightly above average but not exceptional. It ranks #222 out of 653 facilities in Pennsylvania, placing it in the top half, and #12 out of 46 in Philadelphia County, meaning there is only one local option better than it. The facility is improving, with issues decreasing from 10 in 2024 to 8 in 2025. Staffing is average with a turnover rate of 38%, which is below the Pennsylvania average, suggesting some stability among staff. However, the facility has incurred $29,073 in fines, which is concerning as it is higher than 77% of other Pennsylvania facilities, indicating potential compliance problems. In terms of care, there have been specific incidents reported. One serious issue involved the failure to protect a resident from abuse, leading to physical and emotional harm. Additionally, concerns were raised about food safety practices, including unlabeled and improperly dated food items in the kitchen, and unsanitary conditions in the receiving area. Overall, while there are strengths in staffing and improvements in performance, these significant weaknesses highlight the need for careful consideration.
- Trust Score
- C+
- In Pennsylvania
- #222/653
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 38% turnover. Near Pennsylvania's 48% average. Typical for the industry.
- Penalties ⚠ Watch
- $29,073 in fines. Higher than 75% of Pennsylvania facilities, suggesting repeated compliance issues.
- Skilled Nurses ○ Average
- Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 40 deficiencies on record. Higher than average. Multiple issues found across inspections.
60/100
Top 33%
Needs review
10 → 8 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 8 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (38%)
10 points below Pennsylvania average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 38%
Near Pennsylvania avg (46%)
Typical for the industry
Federal Fines: $29,073
Below median ($33,413)
Moderate penalties - review what triggered them
Chain: PARAMOUNT CARE CENTERS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 40 deficiencies on record
1 actual harm
Mar 2025
8 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
Based on staff interview and review of clinical records, it was determined that the facility failed to ensure that care plan meetings were held for one of 24 residents reviewed. (Resident R55)
Finding...
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Based on staff interview and review of clinical records, it was determined that the facility failed to ensure that care plan meetings were held for one of 24 residents reviewed. (Resident R55)
Findings include:
Review of Resident R55's person-centered plan of care indicated that the resident exhibited a decline in communication due to hearing deficit and impaired cognition and thought process related to diagnoses of dementia.
Review of Resident R55's clinical records revealed a nursing note dated June 3, 2024, which indicated, care conference meeting was held and that the resident's daughter in law attended via phone. Further review failed no documented evidence of care conference meetings occurred after June 2024.
Interview with the facility Administrator and Social Worker, Employee E8, conducted on March 27, 2025, at 10:55 a.m. confirmed that the last care conference was conducted in June 2024 with resident and their representative.
Further interview confirmed that the facility failed to conduct a care conference meeting with Resident R55 and their representative in September 2024 and December 2024.
28 Pa. Code 201.29(c.3)(1) Resident rights
28 Pa Code 211.11(d) Resident care plan
28 Pa. Code 211.12(c(1) )Nursing services
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital...
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Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer to the hospital in a timely manner, in writing and in a language and manner they understood for two of 24 residents reviewed for hospitalizations (Residents R31 and R102).
Findings Include:
Review of nursing notes for Resident R31 dated November 20, 2024, at 11 p.m. revealed that the resident was admitted to the hospital with diagnosis of hematoma of the left kidney and abdominal pain.
Further review revealed a note, dated on October 25, 2024, at 2:42 p.m. revealed that Resident R31 was discharged home.
Review of nursing notes for Residents R102 dated March 20, 2025, at 4:35 p.m. revealed that resident was transfer to hospital for evaluation of gastro intestinal bleed.
Review of clinical record revealed no evidence that Residents R31, R102, R27 and R99 representatives were notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood.
Interview with the Nursing Home Administrator, Director of Nursing, on March 26, 2025, at 10:30 a.m. confirmed that the residents' representatives were not notified of the hospital transfers and the reasons for the transfers in writing, and in a language and manner they understood. Further interview confirmed that there was no system in place regarding notifying the residents representatives, in writing, including the reasons, prior to resident transfer or discharge.
28 Pa. Code 201.14(a) Responsibility of license
28 Pa. Code 201.29(a) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement treatment and services for incontinence...
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Based on review of select facility policies and procedures, clinical record review, and staff interview, it was determined that the facility failed to implement treatment and services for incontinence management for one of 24 residents reviewed.(Resident R11).
Findings include:
Review of physician order for Resident R11, dated March 24, 2025, indicated an order to change unrinary Foley Catheter with size 16fr/10ml; change monthly, and as needed, based on clinical indications such as infection, obstruction, or when the closed system is compromised, every night shift, every 4 weeks on Tuesdays, and as needed.
On March 27, 2025, at 1:00 p.m., it was observed that Resident R11 had a Foley Catheter of 16fr/5ml Balloon, instead of the physician ordered size of 16fr/10ml Balloon. At the time of the finding, confirmed the same with a Licensed Nurse, Employee E5.
28 Pa Code 211.12(d)(1) Nursing services
28 Pa Code 211.12(d)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical record, and staff interview, it was determined that the facility failed to monitor and modify interventions consistent with the resident's assessed needs to maintain acceptable parameters of nutritional status for two of four residents reviewed for nutrition (Resident R35).
Findings Include:
Review of facility policy titled, Weight Loss indicated that any resident displaying a significant change in weight of greater than or equal to 5% gain/loss in one month will be reweighed.
Review of facility policy Supplementation dated January 2025 indicated that if an increase in caloric or protein needs are identified, the Dietitian will determine which supplements are appropriate to meet the specific resident's needs. Further review indicated that Residents may benefit from a therapeutic supplement if the present with decreased PO intakes and unplanned weight loss.
Review of Resident R251's quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated March 4, 2025, revealed that the resident was admitted to the facility on [DATE].
Review of Resident R35's admission Nutrition assessment dated [DATE], revealed that Resident R35 was admitted to the facility with diagnoses including muscle wasting and atrophy, high blood pressure, hyperlipidemia (high levels of lipids), depression, and dysphasia (a language disorder). Further review revealed Resident R35 had poor appetite and swallowing difficulty.
Review of Resident R35's weights revealed a documented weight of 183.8 pounds on January 8, 2025, and 172.2 pounds on February 12, 2025, indicating clinically significant weight loss of 6.3% in one month. Further review of Resident R35's clinical record failed to reveal a documented reweight per policy.
Continued review of Resident R35's clinical record failed to reveal documented evidence indicating that Resident R25 was evaluated by the physician to address medical and nutrition issues related to significant weight loss.
Continued review of Resident R35's clinical record failed to reveal documented evidence of nutrition interventions by the Registered Dietitian to address Resident R35's significant weight loss; no documented evidence of nutritional supplements offered to Resident R35 was noted.
Review of facility documentation and interview with the Registered Dietitian, Employee E9, conducted on March 26, 2025, at 1:51 p.m. revealed that the Dietitian had notified the Food Service Director (FSD), a non-medical professional, regarding Resident R35's significant weight loss. Furter interview revealed that nutritional interventions dated February 13, 2025, included resident was put on select menu and preferences were updated. Continued interview confirmed that there is no documented evidence that timely implementation and monitoring of a nutrition therapeutic supplement to address Resident R35's impaired nutrition and clinically significant weight loss.
Interview with the Physician, Employee E10, conducted on March 28, 2025, at 10:20 a.m. revealed that upon identifying Resident R35's significant weight loss on January 8, 2025, the resident was really sick and didn't want to eat and that his mouth was dry, and he didn't have appetite. Employee E10 acknowledged that the foods first or food only approach was not an appropriate nutrition intervention for Resident R35's significant weight loss at that time.
On March 27, 2025, at 10:00 a.m., the facility provided documentation of a progress note, written on March 26, 2026, at 5:22 p.m. which indicated that Resident R35 was evaluated for weight loss on March 3, 2025.
28 Pa. Code 211.10 (d) Resident care policies.
28 Pa. Code 211.12 (d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and review of facility policy, it was determined that the facility failed to develop and implement an individualized person-centered care plan to address a resident's dementia care needs for one of 24 residents reviewed (Resident R84).
Findings Include:
Reviewed facility dementia policy title Care Plan dated in September 2024 states that the plan of care shall be individualized to and based upon, the assessment and diagnosis of a resident.
Review of the admission sheet of Resident R84, revealed that Resident R84 was admitted to the facility on [DATE], with the diagnosis of Dementia (Dementia is not a specific disease but is rather a general term for the impaired ability to remember think, or make decisions that interferes with doing everyday activities).
Review the care plan dated April 21, 2022, revealed that of Resident 84's care plan revealed no care plan with measurable goals and interventions to address the care and treatment need related with dementia care of Resident R46.
During an interview on March 27, 2025, at 12 p.m., the Director of Nursing (DON), confirmed that residents with diagnosis Dementia should be care planned.
28 Pa Code 211.11(d) Resident care plan
28 Pa Code 211.12 (d)(1)(3)(5) Nursing service
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0909
(Tag F0909)
Could have caused harm · This affected 1 resident
Based on staff interviews and clinical record reviews, it was determined that the facility failed to ensure that mattresses and bed frames that were purchased separately were compatible with each othe...
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Based on staff interviews and clinical record reviews, it was determined that the facility failed to ensure that mattresses and bed frames that were purchased separately were compatible with each other for one of 24 residents reviewed (Resident R99).
Findings include:
Observations of Resident R99's bed conduced on March 24, 2025, and March 25, 2025, revealed that the mattress appeared six inches smaller than the metal bed frame; the bedframe slats were exposed on each side. Increased entrapment concerns were observed.
Review of the admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 99, dated October 9, 2024, revealed that the resident was admitted to the facility with diagnoses including neurological conditions, cerebrovascular accident (stroke), cognitive communication deficit, muscle weakness and atrophy.
Interview with the Nurse Assistant, Employee E4, conducted don March 24, 2025, at approximately 12:20 p.m. confirmed that Resident R99 had been utilizing the current bed frame and mattress since admission.
Follow-up observation and interview with the facility administrator and Maintenance Director, Employee E3 conducted on March 25, 2025, at approximately 12:30 p.m. confirmed the above-mentioned finding. Further interview confirmed that the mattress applied on the bedframe is a 36-inch mattress and that the bed frame requires a 42-inch mattress.
Follow-up interview with the maintenance director conducted on March 28, 2025, at approximately 10:00 a.m. revealed that bed audits were last conducted first week of February 2025. Further interview confirmed that mattresses are purchased separately from the bedframe. Further interview revealed, housekeeping must've removed the prior mattress and reapplied the incorrect size (36 inch).
28 PA Code 201.18(b)(1) Management
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, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professio...
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Based on observations, interviews with staff, and a review of facility procedures, 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:
Review of facility policy, Food Storage undated, revealed, Food items will be stored, thawed, and prepared in accordance with good sanitary practice. Continued review revealed, All products shall be dated upon receipt or when they are prepared. Use Date shall be marked on all food containers . and all cooked meat shall be used within 3-4 days.
A tour of the main kitchen was conducted with the Food Service Director (FSD), Employee E6, on March 25, 2025, at 10:05 a.m.
Observations in the main refrigerator revealed two 10-pound ground beef links were unlabeled and undated; opened ham deli meat was dated March 10, 2025; two 10-pound ready to eat roast beef labeled with a received date March 17, 2025; and opened mozzarella cheese labeled with a recieved date December 10, 2024.
Observations of the three-compartment sink revealed Dietary Aid, Employee E7, was manually washing pots and pans. Upon pH test of the sanitation solution (pH test determines how acidic or basic substance is) at approximately 10:15 a.m. revealed no change in pH test strip, indicating the sanitizer being tested was outside the pH range. Follow-up interview with the FSD confirmed this finding.
Interview with the FSD during the kitchen tour confirmed the above-mentioned findings.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(3) Management
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Garbage Disposal
(Tag F0814)
Could have caused harm · This affected multiple residents
Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.
Findings include:
A tour of the main kitchen was ...
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Based on observations and an interview with staff it was determined that the facility did not ensure that garbage and refuse was disposed of properly.
Findings include:
A tour of the main kitchen was conducted with the Food Service Director (FSD), Employee E6, on March 25, 2025, at 10:05 a.m. revealed the following:
Observations of the receiving area and loading dock, that are used by the facility to transport clean food, revealed hundreds of cigarette buds. Further observations revealed the garbage was not covered.
Interview with Food Service Director, Employee E6 along duration of the tour confirmed observations of the receiving and dumpster area.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 207.2(a) Administrator's responsibility
Aug 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical record reviews and interviews with staff, it was determined that the facility failed to follow physician orders related to medication administration for two of 13 residents reviewed (Residents R3 and CL2).
Findings Include:
Facility Policy titled, Medication Administration Policy updated, January 2024 revealed under procedures J. Medication Administration 8. Ensure that the customer swallows all the medication(s). Medication Times BID (Twice a Day) = 0900-1700, TID (Three Times a Day) 0900-1300-2100, QID (Fourt Times a Day) =0900-1300-1700-2100; Before Meals=0600-11:00-1630, After Meals= 0900-1300-1800.
Review of the resident's clinical record indicated resident R3 was admitted on [DATE], with the diagnosis of type 2 diabetes mellitus (a chronic condition that affects the way your body processes blood sugar) with diabetic neuropathy, (nerve damage associated with diabetes), morbid severe obesity.
A review of the physician order dated May 24, 2024, indicated Resident R3 was prescribed NovoLin R Injection Solution 100 Unit/Ml Insulin Regular Human of 12 units at 7:30 a.m., 11:30 a.m. and at 16:30 p.m.
On August 19, 2024, at 9:47 a.m. Resident R3 came out of her room seeking the nurse as her medication was not yet administered. Resident R3 reported that her body is shaking and Resident R3 needs her insulin. License Nurse, Employee E5 approached Resident R3 to address Resident's R3 concerns and confirmed that Resident R3 has not yet received her insulin and morning medication.
During this time Employee E5 prepared the medications and entered Resident R3's room to give her the medications. Resident R3 requested the insulin to be given first as Resident R3 reported that her body is shaking. Employee E5 had a cup with 7 pills and placed it inside of Employee E5 pocket to go get the insulin. Resident R3 requested to leave the cup with medication at her tray instead of taking it with her. Employee E5 listened to Resident R3 and left 7 pills inside the cup and placed it on the resident's tray table. At 9:58 a.m. Employee E5 returned with glucose meter to measure Resident's 3 blood sugar which then she administered the insulin. After, she asked Resident R3 to take her 7 pills which were in the cup. Resident R3 reported I can take them at my own and you don't have to watch me . Employee E5 left the room with Resident R3 being unsupervised with all her medications.
At 10:15 a.m. on the same day, a follow-up interview was conducted with Licensed Nurse Employee E5, who had started her shift at 7:30 a.m. assigned to the Employee E5 was responsible for 26 residents, but by 10:15 a.m., only 4 had received their morning medications. This left 22 residents still awaiting their medication. Employee E5 acknowledged that the policy for administering morning medications required was 9:00 a.m., with an allowable window of one hour before or after. She admitted that she was behind schedule.
On August 19, 2024, at 10:33 a.m., a registered nurse, Employee E7, was assigned to a medication cart on the second floor East unit. Employee E7 reported that she was responsible for 30 residents and had administered morning medication to 14 of them, leaving 16 residents still awaiting their medication.
On August 19, 2024, at 1:33 p.m. an interview with Director of Nursing, Employee E2, Assistant Director of Nursing, Employee E3 and Administrator, Employee E1 confirmed based on the electronic medication administration record (EMAR) which revealed a delay in administering insulin on the following days:
August 19, 2024, the insulin should have been administered at 7:30 a.m. but was administered at 10:07 a.m.
August 18, 2024, the insulin should have been administered at 11:30 a.m. but was administered at 14:56 p.m.
August 18, 2024, the insulin should have been administered at 7:30 a.m. but was administered at 9:46 a.m.
August 17, 2024, the insulin should have been administered at 16:30 p.m. but was administered at 18:01 p.m.
August 17, 2024, the insulin should have been administered at 7:30 a.m. but was administered at 9:48 a.m.
August 16, 2024, the insulin should have been administered at 11:30 a.m. but was administered at 12:55 p.m.
August 14, 2024, the insulin should have been administered at 11:30 a.m. but was administered at 13:48 p.m.
August 12, 2024, the insulin should have been administered at 8:30 a.m. but was administered at 9:44 a.m.
The Director of Nursing, Employee E2, Assistant Director of Nursing, Employee E3 and Administrator, Employee E1 confirmed the delay of insulin medications and license Nurse, Employee E5 leaving the medications at the Resident's R3 tray unsupervised was a violation of the medication administration policy.
Review of the resident's clinical record indicated Closed Record CR2 was admitted on [DATE], and discharged on August 4, 2024, with the diagnosis of low back pain, wedge compression fracture of t11-t12 vertebra, subsequent encounter for fracture with routine healing, unsteadiness on feet, difficulty in walking, muscle weakness, age-related osteoporosis without current pathological fracture.
A review of physician order dated, August 2, 2024, at 07:00 a.m. , indicated showers to be given on Tuesday and Fridays 1st shift document if the patient/resident refuses showers in Health status note. August 2, 2024, was a Tuesday and the Medication Administration report (MAR) did indicate that Closed Resident CR2 did not refuse a shower. Further review of the record under Shower Task did not indicate a shower was given to the Closed Record 2.
A progress note created on August 6, 2024, indicated that a family member called four days later to inquire about not getting a shower for the Closed Record CR2, and a late progress note was entered four days later August 6, 2024, that Closed Record CR2 refused.
On August 19, 2024, at 3:30 p.m. an interview with the Director of Nursing (DON) confirmed that if the Closed Record CR2 MAR did indicate that Closed Record CL2 did not refuse a shower and based on the Shower Task documentation shower was not provided per the physician order.
28 Pa. Code 211.9 (d) Pharmacy Services
28 Pa. Code 211.12 (d)(1)(5) Nursing Services
Jun 2024
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0553
(Tag F0553)
Could have caused harm · This affected 1 resident
Based on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that residents and /or their responsible parties were prov...
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Based on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that residents and /or their responsible parties were provided with the opportunity to participate in their care plan meetings for 4 out of 27 residents reviewed (Residents R64, R54, R85 and R69).
Findings include:
Review of the policy, Resident/patient/Family Care Plan Conferences, with a revision date of August 2023, indicated that it was the policy of the facility to ensure that the resident and his/her family and legal representative are part of the interdisciplinary team and participate in the development and ongoing review of the interdisciplinary plan of care. The policy also indicated that the resident/responsible party will be notified of the care plan conference and that that the method of documentation will be documented in the medical record.
Review of the clinical record for Resident R64 indicated that he resident's last care plan meeting was on held on February 13, 2023.
Review of the clinical record for Resident R54 indicated that the resident's last care plan meeting was held on April 20, 2023.
Review of the clinical record for Resident R85 indicated that the resident's last care plan meeting was held on December 20, 2023.
Review of the clinical record for Resident R69 indicated that the resident's last care plan meeting as held on December 13, 2023.
Review of the clinical record for above referenced resident provided no evidence that the residents received written or verbal notification of the meeting by facility staff, and no evidence that the resident and/or their responsible party participated in one since the above referenced date. That they were provided a copy of the plan to ensure that the resident and his/her responsible party were aware of the plan of care that was developed, participated in its development, and were included decisions related to their care, services, treatments, and discharge planning.
During and interview with the social worker (Employee E14) on June 3, 2024 at 1:46 p.m., it was confirmed that no documentation could be produced to show evidence that the facility ensured that residents and/or their responsible party received notification of a care plan meeting, were provide with the opportunity to participate, and received a copy of their plan of care as required.
28 Pa. 211.5(f) Clinical ecords
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a physician was notified of a resident's refusal t...
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Based on staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a physician was notified of a resident's refusal to take prescribed medication for 1 out of 27 residents reviewed (Resident R39).
Findings include:
Review of the facility's undated policy, Medication/Order Availability indicated that it was written to ensure that all residents have medications/orders administered as ordered. The policy also indicated that medications/orders are to be administered by physician order.
Review of the physician orders for Resident R39 included the diagnoses of history of falling; hypertension (high blood pressure); seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in an individual's behavior, movements, feelings, and consciousness). and diabetes (a chronic condition that happens when you have persistently high blood sugar levels).
Review of Resident R39's May 2024 physician orders included a physician's order for the medication, Lantus (a medication prescribed for the management of the resident's diabetes). The order indicated that the resident will be administered 12 units that will be injected subcutaneously (use of a short needle to inject medication beneath the skin) at bedtime.
Review of the resident's Medication Administration Record (MAR) indicated that that the time of the administration of the medication was 9:00 p.m. Review of MAR's for the moths of March 2024 April 2024 and May 2024 indicated that the resident continuously refused to have the injection administered to him.
Review of the resident's clinical records and physician notes did not indicate that the physician was aware that the resident continuously refused his Lantus and only administered 8 dose of the medication for all three months combined.
Review of the physician's progress note dated March 27, 2024 at 10:41 a.m. indicated that he resident was seen by the physician on the above referenced date for his monthly visit. Continued review of the note indicated that the resident's diabetes was being controlled with Lantus insulin and glipizide.
Review of the MAR for March 2024 indicated that Resident R39 refused 28 out of 31 injections of Lantus scheduled to be administered to him. The MAR for refusals was coded with the 2 which indicated drug refused. Review of the corresponding nursing notes for the 28 days indicated that the resident refused when an attempt was made to administer it.
Review of the physician's progress note dated April 25, 2024 at 10:07 a.m. indicated that the resident was seen by the physician on the above referenced date for his monthly check up. Continued review of the note indicated that the resident's diabetes was being controlled with Lantus insulin and glipizide.
Review of the MAR for April 2024 indicated that Resident R39 refused 28 out of 30 injections of Lantus scheduled to be administered to him. The MAR for refusals was coded with 2 which indicated drug refused. Review of the corresponding nursing notes for the 28 days indicated that the resident refused when an attempt was made to administer it.
Review of the physician's progress note dated May 28, 2024 at 10:43 a.m. indicated that the resident was seen by the physician on the above referenced date for his monthly checkup. Continued review of the note indicated that the resident's diabetes was being controlled with Lantus insulin and glipizide.
Review of the MAR for May 2024 indicated that Resident R39 refused 28 out of 31 injections of Lantus scheduled to be administered to him. The MAR for refusals was coded with 2 which indicated drug refused. Review of the corresponding nursing notes for the 28 days indicated that the resident refused the medication when an attempt was made to administer it.
During an interview with the Unit Manager (Employee E11) on June 3, 2024, at 1:00 p.m. it was discussed that the resident had been refusing the medication Lantus for at least 3 months, and that the physician is writing monthly progress notes and documenting that the resident's diabetes is being controlled by Lantus insulin, despite the refusals. Employee E11 also confirmed that there was no information to produce to show evidence that nursing staff notified the physician that the resident was refusing to take the Lantus insulin that was prescribed to him.
28 Pa Code 211.10 (c) Resident care policies
28 Pa. Code 211.12 (c)(d)(1)(3) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of facility policy, review of clinical records and facility reports, it was determined that the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of facility policy, review of clinical records and facility reports, it was determined that the facility failed to ensure a complete and through investigation for bruises of unknown origin for 1 out of 27 residents reviewed (Resident R69).
Findings include:
Review of the facility Abuse, Neglect and Exploitation, policy with a review date of March 2024 indicated that the facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents including, but not limited to: resident staff or family report of physical abuse; resident report of theft of property or missing property; psychological abuse of the resident observed, physical injury of a resident, of an unknown source.
Review of Resident R69's May 2024 physician orders revealed the diagnoses of pain; delusional disorder (the individual has firmly held false beliefs); hypertension (high blood pressure) and peripheral vascular disease (a common condition in which narrowed arteries reduce the blood flow to the arms or legs).
Review of the resident's quarterly Minimum Data Set (MDS- a periodic assessment of a resident's needs) dated November 27, 2023 indicated that the resident was cognitively impaired. Review of a quarterly MDS dated [DATE] also indicated that the resident was cognitively impaired.
Review of a nursing note dated December 25, 2024 at 10:00 p.m. indicated that the resident was observed by the nurse with purplish colored areas Resident observed with purple colored area n[sic} left hand towards wrist while in hallway. vitals were assessed, supervisor immediately notified. Resident placed onto 24 hours report monitoring. Resident currently under therapy services for Upper extremities. + ROM (range of motion).
Review of the facility investigation regarding the incident indicated that the resident reported to the nurse that the physical therapist came into her room yesterday (April 30, 2024) and that the therapist had her do exercises using her hands. The resident also reported that today (May 1, 2024) that she noticed that she was black, blue and swollen. The resident's Injury type on the investigation was noted as bruises.
During an interview with the Director of Rehabilitation (Employee E15) on June 3, 2024 at 2:27 p.m. the incident, in addition to the resident's statement regarding having physical therapy the day prior to when her bruise was reviewed with the Director of Rehabilitation. The Director of Rehabilitation reported that the resident was not in therapy when the incident occurred, and that the resident was discharged from therapy on December 19, 2023. Employee E15 reported that restorative therapy plan for the resident when therapy ended included exercises for both of her arms.
Review of the investigation regarding the resident's bruising indicated that the resident was the only person interviewed and that the investigation did not show evidence that it was a complete and through investigation that ruled out abuse/neglect. Continued review of facility documentation also did not show evidence of any interviews with staff who worked the shift on which the bruises were discovered or any interviews with staff who worked any previous shifts and who may have provided care to the resident (e.g., nurses, nursing assistants) or may have witnessed interactions with the resident or could provided insight/information as to how the resident sustained bruises of unknown origin. Review of the investigation also did not show evidence that the facility confirmed that a physical therapist or anyone was in her room providing services to her the day before the bruising was found (December 24, 2023), and if so, with who, in addition to other missing pertinent information to rule out neglect/abuse.
During a discussion with the Director of Nursing on June 3, 2024, at 3:30 p.m. it was discussed that no additional information could be found in the investigation to show evidence that the facility conducted a complete and through investigation to ensure abuse/neglect was ruled out for the resident's bruises of unknown origin.
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 201.18(b)(1)(3) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on review of facility documentation, clinical record reviews, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of ...
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Based on review of facility documentation, clinical record reviews, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required for four of four records reviewed related to hospital transfers (Residents R86, R23, R83 and R92).
Findings include:
Review of facility documentation, Hospital Tracking Portal received June 3, 2024, revealed that 21 residents were transferred to the hospital during February 2024, 18 residents were transferred to the hospital during March 2024, and 17 residents were transferred to the hospital during April 2024.
Review of progress notes for Resident R86 revealed a note, dated February 11, 2024, at 6:48 a.m. which indicated that the resident was transferred to a local hospital emergency department via 911 due to a swollen tongue.
Review of progress notes for Resident R23 revealed a note, dated March 20, 2024, at 10:43 p.m. which indicated that the resident had low blood sugar and was ordered by the physician to be transferred to a local hospital emergency department via 911 for further evaluation.
Review of progress notes for Resident R83 revealed a note, dated February 18, 2024, at 12:25 p.m. which indicated that the resident had a change in condition, including signs of gastrointestinal bleeding, and was transferred to a local hospital emergency department for evaluation.
Review of progress notes for Resident R92 revealed a note, dated March 19, 2024, at 10:15 p.m. which indicated that the resident had altered mental status and intractable pain, and was transferred to a local hospital emergency department for evaluation and treatment.
Further review revealed that there was no indication that the Office of the State Long-Term Care Ombudsman was notified of the above facility-initiated emergency transfers for Residents R86, R23, R83 and R92.
Interview on May 31, 2023, at 1:57 p.m. the Nursing Home Administrator confirmed that the Office of the State Long-Term Care Ombudsman was not notified in a timely manner as required of facility-initiated emergency transfers.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(2) Management
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 observation, staff interviews, review of resident records and facility policy, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was develop...
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Based on observation, staff interviews, review of resident records and facility policy, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 27 resident records reviewed (Residents R40, R62, and R65).
Findings include
Review of the facility's care plan policy reviewed January 2023 states, All residents admitted to the facility will have adequate person centered care plan that provide for all their needs in a timely manner.
Review of Resident R40's physician order dated December 11, 2023, instructed to administer oxygen at 2 liters a minute via nasal cannula as needed for shortness of breath. Further orders instructed to clean the O2 (oxygen) concentrator filters on Thursdays during the 11-7 shift and as needed.
Review of Resident R62's physician order dated April 30, 2024, instructed to administer oxygen at 2 liters a minute via nasal cannula continuously for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift and as needed.
Review of Resident R65 physician orders dated August 6, 2021, instructed to administer oxygen at 2 liters a minute via nasal cannula continuously for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift.
On May 29, 2024, at approximately 12:10 p.m. it was observed and confirmed with Registered Nurse Employee E7 that Residents R40, R62 and R65 O2 concentrator filters were covered with thick dust and had not been cleaned.
Further review of the above residents' clinical records revealed no plan of care was developed for the residents use and maintenance of oxygen.
Interview with Unit Manager Employee E29 on June 3, 2024 at 2:00 p.m. confirmed no care plan was developed for Residents R40, R62 and R65 related to their use of oxygen
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observations, review of clinical records, and staff interviews, it was determined that the facility failed to ensure a physician order for neurology was followed for one of 27 residents revie...
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Based on observations, review of clinical records, and staff interviews, it was determined that the facility failed to ensure a physician order for neurology was followed for one of 27 residents reviewed (Resident R62).
Findings include:
Review of Resident R62 clinical records revealed the resident was transferred to the hospital for right arm weakness.
Review of the hospital discharge instructions dated April 30, 2024, indicated a follow up with neurology was to be made in two weeks.
Further review of the resident's clinical record revealed no documented evidence the neurology appointment was scheduled.
This finding was confirmed with the Unit Manager on June 3, 2024, at approximately 2:15 p.m.
28 Pa. Code 211.10 (d) Resident care policies.
28 Pa. Code 211.12 (d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on review of facility policy, observations, record review, and staff interviews, it was determined that the facility failed to provide respiratory care services consistent with professional stan...
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Based on review of facility policy, observations, record review, and staff interviews, it was determined that the facility failed to provide respiratory care services consistent with professional standards of practice for three of 27 residents reviewed, (Residents R40, Resident R62, Resident R65).
Findings Include:
Review of facility policy for Oxygen Administration revised in January 2024 indicates the purpose of this policy it to safely administer oxygen to the resident. Nursing staff will be responsible the correct administration of oxygen. The same policy states when a concentrator is used to wash the filter weekly.
Review of Resident R40's physician order dated December 11, 2023, instructed to administer oxygen at 2 liters a minute via nasal cannula as needed for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift and as needed.
Review of Resident R62's physician order dated April 30, 2024, instructed to administer oxygen at 2 liters a minute via nasal cannula continuously for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift and as needed.
Review of Resident R65 physician orders dated August 6, 2021, instructed to administer oxygen at 2 liters a minute via nasal cannula continuously for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift.
On May 29, 2024, at approximately 12:10 p.m. it was observed and confirmed with Registered Nurse Employee E7 that Residents R40, R62 and R65 O2 concentrator filters were covered with thick dust and had not been cleaned.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure the accurate acquiring, receiving, and administration of medications to meet the needs of each resident for one of 27 residents reviewed (Resident R56).
Findings Include:
Review of facility policy Medication/Order Availability (undated) revealed all residents should have medications/orders administered as ordered. Per review of facility policy, in the case a medication/supply is not available, and to ensure comparable alternative is provided, staff should implement the following procedures:
1. Medication/orders are to be administered per MD order
2. If medication/supply is not available in the facility, MD is to be notified
3. Resident's plan of care is to be reviewed and suggested alternative ordered and provided.
4. Order to be updated accordingly in PCC to reflect any change
5. Discuss any change in order with IDT involved in plan of care
Resident R31 was admitted to the facility on [DATE] for aftercare following a fracture left hip and malignant neoplasm of the endometrium.
Review of Resident R31's physician order revealed Oxycodone HCL 5 mg was to be given every four hours as needed for moderate pain (4-6/10) to severe (7-10) pain and Methocarbamol (for pain relief) 500 mg tablets were to be given four times a day for the resident's fractured femur starting on April 11, 2024.
Review of the nursing progress note dated April 11, 2023, indicated the resident complained of pain 7/10 and the oxycodone was not available to give, and the methocarbamol 500 mg tablets was not received from the pharmacy.
Review of Resident R56's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 14, 2024, revealed the resident was admitted to the facility on [DATE].
Review of Resident R56's clinical record revealed a physician order with a start date of May 11, 2024, to apply Betamethasone Dipropionate Augmented (topical medication cream used to treat eczema) to the scalp every shift for eczema (skin condition characterized by red, itchy rashes).
Review of Resident R56's medication administration record (MAR) revealed nursing staff signed out the order for Betamethasone Dipropionate Augmented as a 9 on May 11, 12, 13, 14, and 15th, 2024. Per the chart codes on the MAR 9 is code for Other / See Nurse Notes.
Further review of Resident R56's clinical record revealed a nurses note dated May 11, 2024, by licensed nurse, Employee E10, that the facility was awaiting pharmacy delivery for Betamethasone Dipropionate Augmented.
Continued review of Resident R56's clinical record revealed no corresponding nurses notes on May 12, 13, 14, or 15th, 2024, regarding the Betamethasone Dipropionate Augmented.
Interview on June 3, 2024, at 10:30 a.m. with licensed nurse, Employee E10, confirmed Resident R56 did not receive the medication cream for eczema on the above dates because the facility was waiting on the pharmacy to deliver the medication. Further interview revealed the eczema cream ended up being on back order.
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
Laboratory Services
(Tag F0770)
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 interview, it was determined that the facility failed to obtain laboratory servic...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, and staff interview, it was determined that the facility failed to obtain laboratory services to meet the needs of one resident's digoxin levels per physician orders of 27 residents reviewed (Resident R55).
Findings include:
Review of Resident R55 clinical record revealed the resident was admitted to the facility on [DATE], diagnosed with Atrial Fibrillation (irregular often fast heartbeat). Review of physician orders revealed the resident was ordered the medication Digoxin to treat the resident's Atrial Fibrillation.
Review of Resident R55 clinical record revealed a plan of care for Digoxin therapy that included goals that the resident would be free from discomfort or adverse reactions related to digoxin use. Interventions included serum digoxin levels monthly or as ordered by the physician and to report to the physician, suspect toxicity if anorexia, nausea, vomiting diarrhea and visual disturbances occur initiated in March 2020.
Further review of Resident R55 physician orders dated October 2020 instructed to check the resident's digoxin levels every six months. The last documented digoxin serum levels were completed in April 2023. It was confirmed with the Unit Manager, Employee E29 on June 3, 2024, at approximately 2:00 p.m. that the facility did not obtain laboratory services for Resident R55's digoxin levels.
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 211.12 (d)(3) Nursing Services
28 Pa. Code 211.12 (d)(5) Nursing Services
Nov 2023
5 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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on review of clinical records, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to promptly notify a resident's representative of ...
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Based on review of clinical records, review of facility policies and procedures and interviews with staff, it was determined that the facility failed to promptly notify a resident's representative of a new pressure ulcer for one of three residents reviewed for pressure ulcer prevention. (Resident R1).
Findings include:
1. Review of facility policy titled Change in a Resident's Condition or Status dated, November 2019, revealed 2. A significant change of condition is a decline or improvement in the resident's status that:
a. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting);
b. Impacts more than one area of the resident's health status;
c. Requires interdisciplinary review and/or revision to the care plan; and
d. Ultimately is based on the judgment of the clinical staff and the guidelines outlined in the Resident Assessment Instrument and 42 CFR 483.20(b)(ii).
4. Unless otherwise instructed by the resident, the Nurse Supervisor/Charge Nurse will notify the resident's family or representative (sponsor) when:
e. The resident is involved in any accident or incident that results in an injury including injuries of an unknown source;
f. There is a significant change in the resident's physical, mental, or psychosocial status;
g. There is a need to change the resident's room assignment;
h. A decision has been made to discharge the resident from the facility; and/or
i. It is necessary to transfer the resident to a hospital/treatment center.
Review of Resident R1's Minimum Data Set assessment (MDS- assessment of a resident's abilities and care needs) dated October 17, 2023, identified that the resident did not have a pressure ulcer/injury (Injury to skin and underlying tissue resulting from prolonged pressure on the skin) , a scar over bony prominence, or a non-removable dressing/device.
Review of wound care consult report dated October 19, 2023, revealed that the resident has unstageable pressure ulcers (ulcer involving loss of skin layers, exposing muscle) to right and left heel.
Review of Resident R1's physician orders dated October 20, 2023, revealed new orders for residents' bilateral heels to pain with betadine and leave it open to air.
Review of Resident R1's entire clinical record revealed no documented evidence that Resident R1's responsible party was notified of the new pressure ulcer and new physician order for wound care.
Interview with Director of Nursing, Employee E2, on November 13, 2023, at 2:00 p.m. confirmed that the facility documentation did not reveal evidence that the Resident R1's responsible party was notified of the new pressure ulcer and new physician order for wound care.
28 Pa. Code 201.29(a) Resident Rights
28 Pa. Code 211.12(d)(3) Nursing services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to deve...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet care needs for one of three residents reviewed. (Resident R1)
Findings include:
Review of an undated facility policy titled, Pressure Ulcer Prevention/Management Program indicated that To provide a standardized action in the management of, and to aid in the prevention or the development of, pressure ulcers. The interdisciplinary team will discuss the evaluation, and a specific individualized plan of care will be developed to address the resident's needs and risk factors in accordance with nursing standards of practice.
Review of admission nursing assessment dated [DATE], revealed tat the resident was using heel boots for prevention of skin issues.
Review of Resident R1's Minimum Data Set assessment (MDS- assessment of a resident's abilities and care needs) dated October 17, 2023, identified that the resident did not have a pressure ulcer/injury (Injury to skin and underlying tissue resulting from prolonged pressure on the skin), a scar over bony prominence, or a non-removable dressing/device. The resident was at the risk for developing pressure ulcer/injuries.
Review of wound care consult report dated October 19, 2023, revealed that the resident has unstageable pressure ulcers to right and left heel which was not present on admission. Resident was ordered to receive heel boots and low air loss mattress.
Review of Resident R1's physician orders dated October 20, 2023, revealed new orders for residents' bilateral heels to pain with betadine and leave it open to air.
Review of care plan for Resident R1 initiated on October 11, 2023, revealed no documented evidence that the facility developed a comprehensive person-centered care plan for Resident R1 with measurable goals and interventions for the care and management of pressure ulcer.
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, and interview with staff and residents, it was determined that the facility failed to d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, and interview with staff and residents, it was determined that the facility failed to develop and implement an effective discharge planning process including the resident's discharge goals and information to the resident's representative of the final plan upon resident's discharge for one of three resident reviewed. (Resident R1)
Findings Include:
Review of Resident R1's Minimum Data Set assessment (MDS- assessment of a resident's abilities and care needs) dated October 17, 2023, identified that the resident did not have a pressure ulcer/injury (Injury to skin and underlying tissue resulting from prolonged pressure on the skin), a scar over bony prominence, or a non-removable dressing/device.
Review of wound care consult report dated November 2, 2023, revealed that the resident has unstageable pressure ulcers (ulcer involving loss of skin layers exposing muscle) to right and left heel which was not present on admission. Resident was ordered to receive Honey gel and calcium alginate to left heel with bordered gauze. Resident was also ordered to receive betadine to right heel and left great toe.
Further review of the MDS revealed that the resident required substantial assistance for toileting, shower/bathe, lower body dressing, putting on and taking off footwear. The resident required partial help from another person to complete indoor mobility, stairs, functional cognition. The discharge goal needed to be independent for all ADL (Activities of Daily Living) and self-care tasks.
Review of nursing note dated November 2, 2023, revealed that the resident required extensive assist for toileting and transfers.
Review of social worker note dated November 3, 2023, revealed that the resident lost her appeal and is going to be discharged home on November 3, 2023. The resident had a walker, shower chair and a commode at home. Resident refused the wheelchair and the hospital bed. Resident to receive home services from home care agency.
Review of discharge summary progress note dated November 3, 2023, revealed that the resident's discharge summary, physician order summary, prescription reviewed with the resident. Resident verbally acknowledged understanding.
Further review of the progress notes and discharge summary revealed no evidence that the resident representative was involved in the final discharge plan or post discharge instruction education.
Review of the progress note, and discharge summary revealed no evidence that the wound care education and appropriate wound care techniques was completed with resident or resident representative. There was no evidence that the resident's ability to perform the wound care was assessed and care giver support and assistance were evaluated for a safe discharge.
Review of Resident R1's Discharge summary dated [DATE], revealed no evidence that the wound care needs were addressed, or the services were obtained without interruption of care after discharge.
Review of Resident R1's care plan initiated on October 11, 2023 revealed no evidence that the facility developed a discharge care plan that focuses on the resident's discharge goals and discharge needs.
Interview with the Social Worker, Employee E3 on November 13, 2023, at 11:38 a.m. stated residents discharged with wound care would be evaluated by home care agency within 48 hours after their discharge. All wound care would be provided by the home care agency based on the level of assistance residents required and the care giver support available. Employee E3 stated Resident R1 was discharged on November 3, 2023. Resident was scheduled to be evaluated by the home agency on November 6, 2023. Employee E3 confirmed that the resident required help in completing wound care and no education were provided to the care giver or representative prior to the discharge. Employee E3 also confirmed that no wound care supplies, wound care medications and treatment were available for resident until November 6, 2023.
28 Pa. Code 201.14 (a) Responsibility of licensee.
28 Pa. Code 211.10 (a) Resident care policies.
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 clinical record review, and interviews with staff, it was determined that the facility failed to follow physician order as ordered by the physician for one of three residents reviewed (Reside...
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Based on clinical record review, and interviews with staff, it was determined that the facility failed to follow physician order as ordered by the physician for one of three residents reviewed (Resident R1).
Findings Include:
Review of clinical record for Resident R1 revealed that the resident was admitted to the facility with diagnosis including Heart Failure and Chronic Kidney Disease.
Review of physician order for Resident R1 dated October 11, 2023, revealed an order for daily weight and to notify the physician with weight gain of 2 pounds in one day or 5 pounds in 3 days.
Further review of physician order dated October 11, 2023, revealed an order to give Lasix (It can treat fluid retention (edema) and swelling caused by congestive heart failure, liver disease, kidney disease, and other medical conditions) 40 milligrams one tablet by mouth as needed for weight gain of 2 pounds in one day.
Review of Medication Administration Record for Resident R1 for the month of October 2023 revealed that on October 28, 2023, resident weighed 154.5 pounds and on October 29, 2023, resident weighed 160.8 pounds which was a weight gain of 6.3 pounds in one day. Further review of the MAR revealed that the staff did not administer Lasix 40 mg as ordered by the physician.
Review of clinical record for Resident R1 revealed no documented evidence that the physician was notified of the weight gain on October 29, 2023.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, staff interviews, it was determined that the facility failed to ensure that a physician...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of clinical records, staff interviews, it was determined that the facility failed to ensure that a physician's wound care recommendations to promote the healing of pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) were followed as ordered and failed to ensure that the pressure ulcer prevention interventions were consistently implemented for one of three residents reviewed (Resident R1).
Findings include:
Review of an undated facility policy titled, Pressure Ulcer Prevention/Management Program indicated that To provide a standardized action in the management of, and to aid in the prevention or the development of, pressure ulcers. The charge nurse, on each shift, is responsible to assess, document and initiate the treatment based on the wound protocol, any changes in the skin integrity of each resident. He/she will document in the medical records in accordance with the facility's documentation policy. An incident report will be completed for any new skin breakdown. All residents that are receiving wound care treatments must be observed by the charge nurse on their designated shift who perform wound care. During this observation, the charge nurse will observe the condition of the dressing and surrounding area to assure that the dressing is intact and the area is clean and appropriate according to practice standards and facility policy. The charge nurse will observe the resident to assure that the following interventions have been consistently implemented on the shift:
Adequate pressure relieving devices
Appropriate and timely repositioning and incontinence care
Assessment for the presence of any pain.
Any change in the status of the wound or of the resident's condition as it pertains to the wound will be documented by the charge nurse in the interdisciplinary progress notes according to the facility's policy at the time that the observation was made.
The interdisciplinary team will discuss the evaluation, and a specific individualized plan of care will be developed to address the resident's needs and risk factors in accordance with nursing standards of practice.
Review of admission nursing assessment dated [DATE], revealed the resident was using heel boots for prevention of skin issues.
Review of Resident R1's Minimum Data Set assessment (MDS- assessment of a resident's abilities and care needs) dated October 17, 2023, identified that the resident did not have a pressure ulcer/injury (Injury to skin and underlying tissue resulting from prolonged pressure on the skin), a scar over bony prominence, or a non-removable dressing/device. The resident was at the risk for developing pressure ulcer/injuries.
Review of wound care consult report dated October 19, 2023, revealed that the resident has unstageable pressure ulcers to right and left heel which was not present on admission. Resident was ordered to receive heel boots and low air loss mattress.
Review of wound care consult report dated October 26, 2023, revealed that the resident was ordered to receive Honey gel and calcium alginate to left heel with bordered gauze. Resident was also ordered to receive betadine to right heel and left great toe.
Review of Treatment Administration Record for Resident R1 for the month of October 2023 revealed that there was no documented evidence that resident received treatment to right heel as ordered by the physician.
Review of clinical record also revealed no documented evidence that the resident received heel boots consistently as ordered by the physician.
Interview with Director of Nursing, Employee E2, on November 13, 2023, at 2:00 p.m. confirmed that the facility documentation did not reveal evidence that the Resident R1's wound care was completed as ordered and there was no evidence that the resident received heel boots consistently as ordered by the physician.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
Aug 2023
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of the clinical record, review of facility policy and interviews with staff and residents, it was determined...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of the clinical record, review of facility policy and interviews with staff and residents, it was determined that the facility failed to ensure complete and accurate resident assessments for one out of 23 residents reviewed. (Resident R87)
Findings Include:
Review of facility policy titled, Nursing Assessment and Reassessment revised April 2023, revealed that residents oral and dental health is to be assessed upon admission.
Review of facility policy, Resident Assessment Instrument Process, revised April 2023, revealed that the Minimum Data Set (MDS) for each resident is completed accurately and timely in accordance with State and Federal regulations. Each resident is to be assessed for specific needs to attain or maintain the resident's highest practicable well-being.
Review of facility policy, Nutrition Documentation Policy revised January 2023 revealed, The dietitian shall complete an in-depth evaluation and recommend dietary interventions as
Appropriate. Appropriate interventions will be individualized according to current standards of clinical practice.
Interview with Resident R87 on August 14, 2023, at 1:53 p.m. revealed the resident had no natural teeth. Further interview revealed she had been receiving hoagies for lunch last week which she couldn't eat. Resident stated she is unable to cut the food into bite size pieces due to tremors and that she had not seen the Registered Dietitian since admission.
Review of Resident R87's MDS dated [DATE], revealed resident was admitted to the facility on [DATE], with diagnoses including tremor (unintentional shaking movements in parts of the body), abnormalities of gait and mobility (limb movements when a person walks), dysphasia (swallowing difficulty), and presence of neurostimulator (chemical messenger in the body). Review of Resident BIMS score (Brief interview for Mental Status) indicated the resident was cognitively intact.
Review of Resident R87 MDS section titled, Oral/Dental Status revealed Resident was coded none of the above were present indicating Resident R87 was admitted with no teeth or oral abnormalities including no natural teeth.
Review of the admission Nutrition Assessment, dated July 19, 2023, failed to reveal an accurate assessment of resident R87's oral/dental status by the Registered Dietitian. The assessment had no indication that Resident R87 had no natural teeth and had difficulty chewing.
Lunch observations conducted on August 15, 2023, at 12:39 p.m. revealed Resident R87 requested help picking the meat off the chicken drumstick and cutting it into bite size pieces. Interview with Resident R87 revealed it was the aids first time cutting my food. Further interview revealed, it would help if food came up cut up.
Interview with the Registered Dietitian, Employee E13, on August 16, 2023, at 1:02 p.m. confirmed she failed to accurately assess Resident R87 upon admission. Further interview acknowledged Resident R87's ordered diet does not accurately reflect the resident's status and that soft textured food would have been a better nutrition intervention for Resident R87.
During an exit interview with the facility Administrator, Employee E1, conducted on August 16, 2023 at approximately 2:45 confirmed that the MDS was inaccurately coded for resident R87 in reference to her oral/dental status.
Title 28 Pa Code 211.5(f) Clinical records
CONCERN
(D)
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 observation, review of clinical records, review of facility policy and procedures, and staff interviews, it was determi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, review of facility policy and procedures, and staff interviews, it was determined that the facility failed to provide a communication device to maintain optimal communication for five of 23 residents reviewed. (Residents R46, R47, R52, R53, R106)
The findings include:
The facility policy titled Communication Procedure under procedure 1. Non-Verbal Communication it revealed Residents that are non-verbal may utilize a writing pad or communication board, your approach and patience go a long way to make them comfortable with openly communicating their needs to you.
A review of clinical record revealed Resident R106 was admitted to the facility on [DATE], with a diagnosis of displaced trimalleolar fracture of left lower leg (fracture of the ankle). An admission summary dated [DATE], notes Resident 106 Cantonese speaking only. Nutritional assessment dated [DATE], notes resident does not speak English. There was no further assessment or information provided in the clinical record how Resident R106 was to communicate their needs.
On July 14, 2023, at 9:58 a.m. revealed Resident R106 had communication barrier and was able to make sound and eye contact, however, did not understand any questions that surveyor was trying to answer. Observation was made during the interview and there was no communication board or pads available to communicate with Resident R106.
An interview with Speech Therapist, Employee E6 on August 15, 2023, at 12:52 p.m. revealed that Employee E6 confirmed that no communication device was provided to resident to communicate her needs.
An interview with nursing staff, unit manager Employee E8 on August 16, 2023, at 9:42 a.m. revealed that resident was given a communication board. Observation was made with E8 inside the resident's R106 room and she as able to communicate her needs of wanting to receive morning care using the communication board.
Observation of Resident R46 conducted during the tour of the second floor on August 14, 2023, at 11:25 a.m. revealed that resident had a blank stare and did not interact with surveyor.
Review of clinical records revealed that Resident R46 was admitted to the facility on [DATE]. Further review of Resident R46's nursing note dated July 18, 2023, revealed that the resident spoke only Russian.
Follow-up observation revealed that resident did not have any communication board or any means of communicating to staff in Russian.
Observation of Resident R52 conducted during tour of the facility on August 14, 2023, at 10:08 a.m. revealed that Resident R52 had difficulty hearing.
Interview with Resident R52 conducted at the time of the observation revealed that he cannot hear and that he has not worn his hearing aid for three months because his hearing aid ran out of battery three months ago. Further, Resident R53 revealed that his hearing aid was just sitting in his drawer.
Follow up observation of Resident R53 conducted on August 16, 2023, at 1:44 p.m. revealed that Resident R53 did not have hearing aids on.
Interview with Resident R53 at the time of the observation revealed that the nurse took his hearing aids and did not return it.
Interview with Licensed nurse, Employee E12 confirmed that resident did not have hearing aids on and that she has the hearing aids because they needed batteries.
An interview was held with Activity Director Employee, E7 on August 16, 2023, at 10:02 a.m. who reported it's her responsibility to issue communication board to those resident's who do not speak English. Employee E7 reported that there Resident R47 did not speak English and had a communication board by her bedside and at the nursing station on the second floor. Observation was completed at the time of Resident's R47 room and nursing station on the second floor and Employee E7 confirmed that there was no communication board available for Resident R47.
28 Pa. Code 211.10(c) Resident care policies
28. Pa Code 211.12 (d)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interviews, it was determined that the faciltiy failed to investigate, as...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interviews, it was determined that the faciltiy failed to investigate, assessed and notified the physician of a resident's burn and to follow physician's orders related to weight loss for 2 of 23 residents reviewed. (Residenst R49 and R46)
Findings include:
Resident R49 was admitted to the facility on [DATE] with the following diagnoses of cerebral infarction; recurrent; mild cognitive impairment; hemiplegia (complete paralysis to one side of the body) and hemiparesis (weakness to one side of the body), following unspecified cerebrovascular disease affecting left dominant side; and muscle wasting and atrophy.
Review of Resident R49's clinical record revealed a nursing note dated March 1, 2023 which indicated Resident spilled her cup of coffee on her lap. Thighs a little pink in areas. No blisters, skin intact. Denies pain or discomfort. Resident was returned to her room where she was assessed by charge nurse and unit manager.
Review of Resident R 49's most recent BIMS (Brief Interview for Mental Status) revealed a score of 13, indicating Resident R49 is cognitively intact.
An interview on August 16, 2023 with Resident R49 revealed, Yes, I did spill a cup of coffee. I guess it did hurt. Resident R49 was unable to recall any further details.
A request was made on August 15, 2023 at 2:00 p.m. to the Director of Nursing, Employee E2 to review the investigation related to Resident R49's spilling the cup of coffee on her lap. A follow up interview on August 16, 2023 at 9:15 a.m. with Director of Nursing, Employee E2, revealed that the facility had no investigation related to the burn sustained by Resident R49.
An interview with Licensed nurses, Employee E1 and Employee E15, confirmed that no written skin assessment was completed and burn incident was not reported and investigated. No additional documentation related to monitoring Resident R49 after sustaining a burn was available and no documented evidence that physician was notified.
Review of clinical records revealed that Resident R46 was admitted to the facility on [DATE].
Further review of Resident R46's July 2023 physician's orders revealed an order for weight on admission and
weekly x 4 weeks for 28 Days.
Review of Resident R46's care plan initiated July 19, 2023 revealed that Resident R46 was at risk for malnutrition related to poor intake, history of unintended weight loss, and need for mechanically altered diet texture. Interventions developed included weekly weights x 4 weeks, followed by monthly weights.
Further review of Resident R46's clinical record revealed a weight of 131.8 pounds was obtained on July 18, 2023. Review of Resident R46's entire clinical record revealed no evidence that weekly weights were obtained as ordered by the physician.
28 Pa Code 211.10(d) Resident care policies
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1) 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, resident and staff interviews, it was determined that the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, resident and staff interviews, it was determined that the facility failed to monitor meal and nutritional supplement consumption for three of 23 residents reviewed (Resident R261, R87, R95)
Findings include:
Review of facility policy titled, Weight loss/gain maintenance Program, revised April 1, 2023, revealed, Ongoing weights, meal and supplement consumption, and general nutritional status shall be monitored by both Nursing and the Dietitian. Documentation as per weight procedure; resident's progress and response to approaches should be included in the Dietitian's notes, if needed, and in the IDT Quarterly notes.
Review of Resident R261's clinical record revealed resident was admitted to the facility on [DATE], with diagnoses including malnutrition (condition that results from lack of sufficient nutrients in the body which causes fatigue and dizziness) and a pressure ulcer (injury to skin and underlying tissue resulting from prolonged pressure on the skin).
Review of Resident R261's admission nutrition assessment dated [DATE], revealed a recommendation by the Registered Dietitian, Employee E13, for ProSource supplement to aid in wound healing (nutritional supplement that is typically used to meet the needs of people who are nutritionally at risk for protein malnutrition).
Review of Resident R261's physician orders failed to reveal an order for ProSource Nutritional Supplement.
Interview with the Registered Dietitian, Employee E13, conducted on August 16, 2023, at 1:00 p.m. revealed she did not place an order for this supplement because she forgot. Employee E13 stated, totally my mistake.
Review of Residents R95's Quarterly Minimum Data Set (MDS - federally mandated assessment of a resident's abilities and care needs) dated July 20, 2023 revealed that the resident was admitted to the facility on [DATE], and had the diagnoses of hypothyroidism (he thyroid gland doesn't make enough thyroid hormone), hypertension (high blood pressure), and heart failure (progressive heart disease that affects pumping action of the heart muscles). A review of Resident R20's BIMS (Brief Interview of Mental Status) revealed a score of thirteen, which indicated that the resident was cognitively intact.
Review of Resident R20's clinical records revealed Resident R20 had a documented weight of 223 pounds on April 3, 2023, and a weight of 176 on August 7, 2023; indicating a significant weight loss of 21% in five months.
Further review of Resident R20's clinical record revealed nutrition interventions included encouraging resident to come to the dining room for meals, boost nutritional supplement, Remeron (anti-depressant), double protein meal portions, and ice cream with lunch and dinner.
Review of physician orders revealed an order for Boost VHC one time a day 8 oz, dated, July 26, 2023. Further review failed to reveal an order for double protein portions. Further review failed to reveal an order for double protein portions.
Observations of dining conducted on August 14, 2023, at approximately 12:00 p.m. revealed Resident R95 was not dining in the dining room.
Follow-up observations of dining conducted on August 15, 2023, at 12:37 p.m. revealed Resident R95 was not dining in the dining room; resident was dining in her room. Observations of Resident R95's meal slip revealed that resident was to receive double protein portions. Resident R95's meal consisted of one small chicken drumstick and macaroni and cheese.
Observations conducted on August 16, 2023, at approximately 12:17 p.m. revealed resident had not received a double protein portion during her lunch meal. Further observations revealed resident had declined her ice cream and was not offered an alternative option.
Interview with the Registered Dietitian, Employee E13, at 12:22 p.m. confirmed that resident had not received a double protein portion during lunch. Further interview confirmed that the suggested nutritional interventions were not being followed and that Employee E13 was not aware. Further interview revealed Employee E13 was unaware that Resident R95 prefers to eat in her room because she likes to be taken to her room right away; Resident R95 stated, they don't let you leave once you're finished.
Follow-up interview with the Registered Dietitian at 12:57 p.m. confirmed that she had not evaluated the nutritional interventions prescribed. Employee E13 was not aware Resident R95 had not been receiving double protein portions and that she had not been eating in the dining room the past two days.
Interview with Resident R87 on August 14, 2023, at 1:53 p.m. revealed the resident had no natural teeth. Further interview revealed she had been receiving hoagies for lunch last week which she couldn't eat. Resident stated she was unable to cut they food into bite size pieces due to tremors and that she had not seen the Registered Dietitian since admission.
Review of Resident R87's MDS dated [DATE], revealed resident was admitted to the facility on [DATE], with diagnoses including tremor (unintentional shaking movements in parts of the body), abnormalities of gait and mobility (limb movements when a person walks), dysphasia (swallowing difficulty), and presence of neurostimulator (chemical messenger in the body). Review of Resident BIMS score (Brief interview for Mental Status) indicated the resident was cognitively intact.
Review of Resident R87's MDS section titled, Oral/Dental Status revealed Resident was coded none of the above were present indicating Resident R87 was admitted with no teeth or oral abnormalities including no natural teeth.
Lunch observations conducted on August 15, 2023, at 12:39 p.m. revealed Resident R87 requested help picking the meat off the chicken drumstick and cutting it into bite size pieces. Interview with Resident R87 revealed it was the aids first time cutting my food. Further interview revealed, it would help if food came up cut up.
Review of Resident Diet Order dated July 18, 2023, revealed Resident R87 was ordered a regular textured diet.
Review of Resident R87's clinical record revealed a documented weight of 145.4 pounds on July 18, 2023, and 141 pounds on August 8, 2023, indicating a downward weight trend.
Interview with the Registered Dietitian, Employee E13, on August 16, 2023, at 1:02 p.m. confirmed she failed to accurately assess Resident R87 upon admission. Further interview acknowledged Resident R87's ordered diet did not accurately reflect the resident's status and that soft textured food would have been a better nutrition intervention for Resident R87.
28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 211.6 (d) Dietary services
28 Pa. Code 211.12 (c)(5) Nursing Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, review of a clinical records, review of facility policy and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and services for ...
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Based on observation, review of a clinical records, review of facility policy and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and services for three of 22 residents reviewed. (Resident R40, R99, and R108 ).
Findings Include:
A review of the facility policy titled Oxygen Administration revised January 2023, revealed Oxygen administration will be carried out only with a physician's order. A licensed nurse or other staff person trained in the use of oxygen will be on duty and be responsible for the correct administration of oxygen to the resident. It further stated under number 11. Care and Use of Prefilled Disposable Humidifier under i. Label humidifier with date and time opened. Change humidifier and tubing weekly.
On August 14, 2023, at 10:06 a.m. observation revealed Resident R99's oxygen's humidifier and oxygen tubing were not labeled with the opened date.
On August 14, 2023, at 10:59 a.m. an observation with a license nurse, unit manger Employee, E8 confirmed the observation of humidifier and tubing not being labeled.
A review of Resident R99's physician order dated July 17, 2023 revealed Change humidifier bottle once weekly on THU (Thursday) during the NIGHT shift and PRN (as needed). *Please Date Supplies. Medication Administration Record (MAR) indicated that the humidifier was changed every Thursday during the night shift. The last humidifier documented as changed was on August 10, 2023; however, it was not dated.
On August 14, 2023, at 12:55 p.m. observation revealed Resident R108's oxygen's humidifier and tubing were not labeled.
On August 14, 2023, at 1:00 p.m. an observation with a license nurse, unit manger Employee, E8 confirmed the observation of humidifier and tubing not being labeled.
A review of Resident's R108's clinical record did not indicate a physician order for oxygen therapy. An interview with license nurse, unit manger Employee, E8 on August 16, 2023, at 1:06 p.m. revealed that there was no order for oxygen therapy, and it was initiated after the surveyor's interview.
Observation of Resident R40 on Auguat 14, 2023 at 10:30 a.m. revealed that the resident was in bed, awake with the head of the bed elevated.
Further observation revealed Resident R40 was on an oxygen concentrator (a machine that produces oxygen gas) at 1.5 liters/minute via nasal cannula. Further observation revealed that Resident R40's oxygen concentrator was emitting a loud sighing noise. Further, the oxygen tubing did not have a date affixed on the tube indicating when the oxygen tubing was installed.
Interview with Resident R40 conducted at the time of the observation revealed that the oxygen concentrator has been making the loud noise since she got it on her admission. Further Resident R40 revealed that the noise was bothersome especially when she wants to sleep but that she just had to get used to it. Further, Resident R40 revealed that she thought that the noise was normal.
Interview with Licensed nurse, Employee E3 revealed that oxygen tubing were supposed to be changed every shift and whenever necessary.
Follow-up observation of Resident R40 conducted on August 15, 2023, at 8:52 a.m. revealed that resident was sitting on her wheelchair at the foot of her bed. Further, Resident R40 had oxygen on at 1.5 liters/minute.
Review of physician's note date July 31, 2023, revealed that Resident R40 was positive for shortness of breath. negative for cough, chest tightness and wheezing. Nursing note dated July 16, 2023, revealed that around dinner time Resident R40 complained of shortness of breath and oxygen was provided.
Review of physician's order revealed that there was no order for oxygen for Resident R40 until August 16, 2023.
28 Pa. Code 211.12(d)(1) Nursing services
28 Pa. Code 211.12(d)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, review of clinical records and staff interview, it was determined that the facility failed to disposed of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, review of clinical records and staff interview, it was determined that the facility failed to disposed of a controlled drug and ensure proper accountability of narcotic medications.
Findings include:
Interview and observation was conducted on August 18, 2023 at 12:36 p.m revealed that there was one opened bottle of Morphine Sulfate (concentrate) oral solution 20 mg/ml. and an unopened bottle of Lorazepam Intensol Oral Concentrate 2 mg/ml. Further both bottles were labelled with Resident R 109's name.
A review of the clinical record revealed Resident 109 was admitted to the facility on [DATE], with cerebral infarction due to thrombosis of right middle cerebral artery (embolic stroke ) and passed away on July 13, 2023.
Review of Resident R109's clinical record revealed a physician order initially dated June 13 ,2023 for Lorazepam Intensol Oral Concentrate 2 mg/ml and Morphine Sulfate (concentrate) oral solution 20 mg/ml.
A review of the controlled medication record accounting for the above narcotic medications conducted on August 17, 2023, at 12:36 p.m. revealed that Lorazepam Intensol Oral Concentrate 2 mg/ml and Morphine Sulfate (concentrate) oral solution 20 mg/ml were not destroyed or disposed by the facility after Resident R109 was July 13, 2023.
Review of the Individual Patient Controlled Substance Administration record for Resident R109's Morphine Sulfate (concentrate) oral solution 20 mg/ml. revealed that on July 17, 2023, the remaining balance was 14.5 ml. Further, there was no documented evidence that the 14.5 ml of Morphine Sulfate (concentrate) oral solution 20 mg/ml was accounted for every change of shift.
Review of the Individual Patient Controlled Substance Administration record for Resident R109's Lorazepam Intensol Oral Concentrate 2 mg/ml revealed that the remaining balance was 30 ml. Further review of the controlled medication record accounting revealed, there was no documented evidence that the 30 ml of Lorazepam Intensol Oral Concentrate 2 mg/ml was accounted for every change of shift.
Interview with the Director of Nursing, Employee E2 conducted on August 18, 2023, at 1:18 p.m. confirmed Resident 109 received the last Morphine Sulfate dosage on July 7, 2023 and that was the last accountability record from the facility. Lorazepam Intensol Oral Concentrate was never used and the accountability log for this controlled drug was not completed to keep a count of unused dosages. Further, the Employee E2 confirmed that the facility did not have a shift-to-shift accounting for both the Morphine Sulfate (concentrate) oral solution 20 mg/ml and for the Lorazepam Intensol Oral Concentrate 2 mg/ml. Further, Director of Nursing was not able to provide explanation to why the controlled drugs were not destroyed.
28 Pa Code 211.12 (c)(d)(1)(3)(5) Nursing service
28 Pa Code 211. (c)(k) Pharmacy services
28 Pa Code 211.5(f) Clinical records
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that dishes were cleaned under sanitary conditions in accordance with profes...
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Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to ensure that dishes were cleaned under sanitary conditions in accordance with professional standards for food service safety.
Findings Include:
A tour of the Food Service Department conducted on August 14, 2023, at 9:18 a.m. with Employee E17, Food Service Manager, revealed the following concerns:
Review of undated facility policy titled, Manual Ware Washing indicate that appropriate test strips will be used to ensure the concentration of the 3rd compartment meets manufacturer guidelines . Temperature of wash sink and PPM of sanitizing sink will be recorded on the Pot Sink Temperature and PPM log.
Review of undated facility policy titled, Dish Machine, indicated that dish machine temperatures should be monitored and recorded on the Dish Machine Temperature Log.
Review of facility documentation, titled, dish machine Ware washing temperature Log, failed to reveal documented temperatures August 7, 2023, through, August 14, 2023.
Review of facility documentation, titled, three compartment sink Ware washing temperature Log, failed to reveal documented temperatures August 8, 2023, through, August 11, 2023; August 13, 2023, through August 14, 2023.
Observations of the 3-compartment sink revealed a dietary employee had just finished utilizing the sink to wash, rinse, and sanitize large pots. Subsequent testing of the sanitizing solution revealed that the sanitizing sink did not have adequate levels of sanitizing solution. When the sanitizing compartment was tested with the sanitizing strips, the solution was 500 ppm (parts per million).
Interview with the Food Service Manager, Employee 17, confirmed that the chemical solution in the third sink should be between 150 and 400 ppm.
Observations were confirmed by Employee E17, Food Service Manager, along the duration of the tour of the dietary department.
28 Pa. Code 211.6 (f) Dietary Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy and interviews with staff, it was determined that the facility failed to promot...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policy and interviews with staff, it was determined that the facility failed to promote care for residents that maintains or enhances dignity and respect related to dining for two of two dining rooms observed. (First and Second floor, dining rooms).
Findings include:
A facility policy titled Resident Right revised January 2023 under section 5 Respect and Dignity revealed The resident has a right to be treated with respect and dignity.
Observations of the First dining hall on August 14, 2023, at 12:06 p.m. revealed the following:
Four tables were connected to make a long dining table with nine residents sitting waiting to be served, only two residents were served a meal at 12:06 p.m. The third resident was served at 12:32 p.m. which was 26 minutes later. The rest of the resident were served after 12:32 p.m.
Another table with three residents seated, only one resident was served a meal at 12:06. The one resident who was not served started to roll out with her wheelchair of the dining hall and staff redirected her couple of time until the next food truck arrived. The second resident received her meal at 12:30 p.m.
Another table had two residents sitting at the table and only one resident was served at 12:06 p.m. and the second was served at 12:24 p.m.
A license nurse, unit manager Employee E8 confirmed the observations.
On August 15, 2023, at 12:20 p.m. observations were made of the first-floor dining hall there was a long table with 8 residents sitting at the long table. At 12:20 p.m. 5 residents received their food. The next truck came at 12:30 p.m. and the 3 resident who did not receive their food received it 10 minutes later.
Dining observation of the second-floor unit conducted on August 14, 2023, at 12:15 p.m. revealed that one food truck arrived. Further, staff started serving the trays to residents in the dining room.
Further observation revealed that at 12:41 p.m. five residents did not get their lunch tray while four other residents were already eating.
Further observation revealed that, Resident R84 was yelling repeatedly Where's my food?
Interview with licensed nurse Employee E15 at the time of observation revealed that the rest of the trays were coming and that they were in the second truck but that the truck had not arrived yet.
Further, observation revealed that at 12:52 p.m., the second truck arrived.
Dining observation for breakfast on the second-floor unit conducted on August 15, 2023, at 8:12 a.m. revealed that the trays from first truck has already been served and some residents were already eating.
Observation conducted at 8:22 a.m. revealed that six residents were eating their breakfast and seven residents not eating.
Interview with licensed nurse, Employee E15 conducted at the time of observation revealed truck has not yet arrived but coming, further, Employee E15 revealed that this is the normal truck delivery schedule not just this week.
Further observation revealed that at 9:16 a.m. the second cart arrived.
Observation conducted on August 14, 2023, at 11:49 during dining observation on the second-floor unit revealed that Resident R83 was in the dining room, sitting in a geri-chair in a table located in the middle of the dining room waiting for lunch. Further, there were nine residents in the dining room waiting for lunch and one nurse's aide sitting in the corner of the dining room.
Further observation revealed that Resident R83 was yelling out for help and attempted to remove her blouse several time.
Further observation revealed that nurse's aide who was sitting in the corner of the dining room sitting in the corner of the room provided with verbal cuing by yelling out to resident from across the room to put her blouse back on every time Resident R83 attempts to take her blouse off.
Review of clinical record revealed that Resident R83 was admitted to the facility on [DATE]. Further review of Resident R83's clinical record revealed that Resident R83 had a diagnosis of Non-Alzheimer's Dementia.
28 Pa. Code 201.29(d) Resident Rights
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and staff interview, it was determined that the facility failed to ensure that notices of Med...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy and staff interview, it was determined that the facility failed to ensure that notices of Medicare non-coverage Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) were provided timely for three of three residents reviewed (Residents R47, R111 and R370).
Findings include:
Facility Policy titled Advance Beneficiary Notice (ABN and Notice of Medicare Non-coverage (NOMIC) guidelines revised January 2023 indicated [NAME] is issued when you expect Medicare to deny payment for an item or services because it is not reasonable and necessary under Medicare Program standards or because Medicare considers it custodial care. You should only provide ABNs to beneficiaries enrolled in Original (Fee -For -Service) Medicare. The ABN allows the beneficiary to make an informed decision about whether to get services and accept financial responsibility for those services if Medicare does not pay. The ABN service as a proof that the beneficiary knew prior to getting the service that Medicare might not pay.
Review of Resident R47's Medicare Non - Coverage information indicated that Resident R47 was to receive a SNFABN.
Review of facility documentation indicated that Resident R47 had last covered date of Part A service ended on August 11, 2023, and was discharged . There was no evidence that Resident R47 received a SNFABN.
Review of Resident R111's Medicare Non -Coverage information indicated that Resident R111 was to receive a SNFABN. Resident R111 last covered day of Part A service ended on April 26, 2023, and Resident R111 was discharged home. There was no evidence that Resident R111 did receive a SNFABN.
Review of Resident R370's Medicare Non -Coverage information indicated that Resident R370 was to receive a SNFABN. Resident R370 last covered day of Part A service ended on July 14, 2023, and Resident R370 was discharged home. There was no evidence that Resident R370 receive a SNFABN.
An interview with Employee E4, Social Worker Director on August 15, 2023, at 1:54 p.m. confirmed that Residents R47 and R111 and R370 did not receive a SNFABN as facility does not have a practice to provide SNFABN notices to residents who choose to decide to be discharge from the facility. Employee E4 confirm that the facility failed to give SNFABN information to beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility.
An interview with Nursing Home Administrator on August 15, 2023, at 3:00 p.m. confirmed that facility did not meet its obligation to inform the beneficiary of his or her potential financial liability before they were discharged .
28 Pa. Code: 201.18(e)(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 review of facility policies, clinical records reviewed, and staff interviews, it was determined that the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records reviewed, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet care needs related to communication, dialysis treatment, oxygen therapy, hearing, behaviors and oral status for seven of 23 residents (Resident R40, R46, R53, R83, R87, R106, R368)
Findings include:
Review of facility policy Care Plan dated January 2023, indicated : It is the policy of [NAME] Edge that all residents admitted to the facility will have adequate person-centered care plans that provide for all their needs in a timely manner.
A review of clinical record revealed Resident R106 was admitted to the facility on [DATE], an admission summary dated [DATE], notes Resident 106 Cantonese speaking only. Nutritional assessment dated [DATE], notes resident does not speak English. There was no further assessment or information provided in the clinical record how Resident R106 is able to communicate their needs.
A comprehensive care plan was reviewed and did not document any interventions to be used on how to communicate with Resident R106.
An interview was conducted with Director of Nursing and Nursing Home Administrator on August 16, 2023, at 3:09 p.m. who confirmed that a care plan was not developed until August 15, 2023.
A review of clinical record revealed that Resident R368 was admitted to the facility on [DATE], with a diagnosis with dependence on renal dialysis, unspecified cirrhosis of liver (severed liver damage).
A review of Resident R368's August 2023 physician order dated August 10, 2023, revealed that the resident was to have dialysis treatment 3 times a week on Tue-Thu-Sat at 7:10 a.m.
Review of Resident R368's current care plan failed to reveal goals and interventions related to dialysis treatment.
An interview with license nursing staff, unit manager Employee E8 on August 16, 2023, at 9:30 a.m. confirmed that Resident 368 was receiving dialysis therapy; however, there was no comprehensive care plan.
Observation of Resident R40 on August 14, 2023 at 10:30 a.m. revealed that the resident was in bed, awake with the head of the bed elevated.
Further observation revealed Resident R40 was on an oxygen concentrator (a machine that produces oxygen gas) at 1.5 liters/minute via nasal cannula.
Follow-up observation of Resident R40 conducted on August 15, 2023, at 8:52 a.m. revealed that resident was sitting on her wheelchair at the foot of her bed. Further, Resident R40 had oxygen on at 1.5 liters/minute.
Review of Physician's note date July 31, 2023, revealed that Resident R40 was positive for shortness of breath. negative for cough, chest tightness and wheezing. Nursing note dated July 16, 2023, revealed that around dinner time Resident R40 complained of shortness of breath. On assessment resident oxygen level at room air was 93%. Oxygen was provided and 98% was noted.
Review of resident care plan revealed that there was no care plan for oxygen and respiratory until August 16, 2023.
Observation of Resident R53 conducted on August 14, 2023, from 9:23 a.m. to 10:30 a.m. during the tour of the facility revealed that the resident was in bed, awake.
Interview with Resident R53 revealed that resident had difficulty hearing. Further observation revealed that resident did not have a hearing aid on.
Interview with Resident R53 revealed that he had a hearing aid but has not used it for three months because the battery was dead. Further Resident R53 revealed that the staff knew that the battery was dead, but nobody came to replace the batter.
Follow-up observation and interview with Resident R53 conducted on August 15, 2023, at 9:05 a.m. revealed that he didn't have his hearing aid on. Further Resident R53 revealed that nobody came to replace the battery of his hearing aid.
Follow-up observation of Resident R53 conducted on August 17, 2023, at 9:50 a.m. revealed that Resident R53 did not have his hearing aid on. Interview with licensed nurse, Employee E12 revealed that she was just about to change Resident R53's hearing aid battery.
Review of Resident R53's care plan revealed that there was no care plan addressing his hearing deficits and use of hearing aid.
Observation conducted on August 14, 2023, at 11:49 a.m. during dining observation on the second-floor unit revealed that Resident R83 was in the dining room, sitting in a geri-chair in a table located in the middle of the dining room waiting for lunch.
Further observation revealed that Resident R83 was yelling out for help and attempted to remove her blouse several time.
Review of Resident R83's medical record revealed that Resident R 83 had a diagnosis of Anxiety Disorder, Unspecified, Major Depressive Disorder, Psychosis not due to a substance or known physiological condition, Delusional Disorder, Unspecified Dementia, Psychotic Disturbance, Mood Disturbance and Anxiety.
Review of physician's orders revealed order for Clonazepam Tablet 0.5 MG, Give 1 tablet by mouth at bedtime for agitation/anxiety, Risperdal Tablet 0.5 milligrams (mg) (risperidone),by mouth every 12 hours for psychosis, Trazodone HCl Tablet 50 mg give 1 tablet by mouth at bedtime for depression
Review of Resident R83's care plan revealed that there was no care plan that addresses Resident R83's behaviors.
Interview with Resident R87 on August 14, 2023, at 1:53 p.m. revealed the resident had no natural teeth. Further interview revealed she had been receiving hoagies for lunch last week which she couldn't eat. Resident stated she is unable to cut they food into bite size pieces due to tremors and that she had not seen the Registered Dietitian since admission.
Review of Resident R87's MDS dated [DATE], revealed resident was admitted to the facility on [DATE], with diagnoses including tremor (unintentional shaking movements in parts of the body), abnormalities of gait and mobility (limb movements when a person walks), dysphasia (swallowing difficulty), and presence of neurostimulator (chemical messenger in the body). Review of Resident BIMS score (Brief interview for Mental Status) indicated the resident was cognitively intact.
Review of Resident R87's care plan failed to reveal interventions regarding Resident R87's oral status.
Observation of Resident R46 conducted during the tour of the second floor on August 14, 2023, at 11:25 a.m. revealed that resident had a blank stare and did not interact with surveyor.
Review of clinical records revealed that Resident R46 was admitted to the facility on [DATE]. Further review of Resident R46's nursing note dated July 18, 2023, revealed that the resident spoke only Russian.
Further review of Resident R46's clinical record revealed that Resident R46 did not have a care plan to address resident's language (Russian)
28 Pa. Code 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based or observation, interview with staff and residents and review of facility policy, it was determine that the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based or observation, interview with staff and residents and review of facility policy, it was determine that the facility failed to implement a water management program for the prevention, detection, and control of water borne contaminants, such as Legionella (a bacteria that causes Legionnaire's Disease) and based on observation, interview with staff and review of facility policy, it was also determined that the facility failed to follow acceptable infection control practices related to the care of urine bags for two of eleven residents observed. (Residents 13 and R42)
Findings include:
Review of facility policy entitled Maintenance and monitoring of water system with initiation date of November 2017 and reviewed/revised on June 2023, revealed that under section Policy To reduce the potential for nosocomial infections by biological agents in aerosolizing water system, the Utilities management Program will include the maintenance and monitoring of the facility's water system for the Legionella bacterium, Pseudomonas, Stenotrophomonas, Acinetobacter species and Nontuberculous mycobacteria. In conjunction with the infection control committee, the plan will include prevention, surveillance, Environmental culturing (as necessary), remediation (if and when necessary), reporting. Under section Prevention Physicians and other healthcare personnel are educated to maintain a heightened suspicion for legionella as a cause of nosocomial pneumonia. Under section Surveillance The director of Maintenance in conjunction with the Infection Control Practitioner, Director of Environmental Services, Clinical Laboratory Director, Nursing, and others as deemed necessary by the facility, shall perform a clinical and environmental risk assessment of the facility to determine where culturing should be performed. Steps for collecting and processing environmental specimens for Legionellosis including collecting water samples from environmental sources and other aerosolizing water sources can be found in the CDC (Center for Disease Control) website.
Review, of Legionella Water Testing dated June 21, 2023, performed by Director of Maintenance, revealed a photocopy of an image of a rapid test stick and written on the paper Test Result-Negative. Further, there was no indication of the location where the water was tested.
Interview with Maintenance Director Employee E10 conducted on August 15, 2023, at 1:32 p.m. revealed that the facility should tests their water system for legionella twice a year. Further Employee E10 revealed that he conducted water testing for Legionella on June 21, 2023, using a rapid test and that that was the only time the facility's water was tested. Further, Employee E10 revealed that he only tested on e area (room [ROOM NUMBER]) using a rapid test. Further Maintenance Director revealed that the facility did not do any testing before June 21, 2023.
There was documented evidence that the facility had tested their water system for legionella.
Interview with infection control nurse, Employee E11 conducted on August 15, 2023, at 1:49 p.m. revealed that the water from room [ROOM NUMBER] was tested because the facility suspected the resident in that room of having legionellosis.
Interview with the Nursing Home Administrator, Employee E1 conducted on August 16, 2023, at 2:18 p.m. confirmed that the facility did not have their water tested for legionella. Further, facility administrator revealed that the facility had just hired a company to check their water system for legionella twice a year.
Review of Urinary Catheter (Infection Control) Policy updated on May 2022 revealed that under section Policy: To provide guidance in the preventive measures for controlling common infections for residents with a urinary catheter as part of the overall infection control program. The facility is committed to providing a safe and healthy environment for residents and to minimize or prevent the spread of infections. Under section Procedure: #6. Do not allow the catheter tubing, bag, or spigot to touch the floor.
Observation of the second-floor unit conducted on August 14, 2023, from 9:23 a.m. to 10:30 a.m. during the tour of the facility revealed that Resident R13 was in her room, in bed, sleeping. Further observation revealed that Resident R13 had a half full urine bag. Further, Resident R13's urine bag was lying on the floor.
Review of Resident R13's physician's orders revealed an order for Foley catheter French 18 for Chronic retention.
Interview with Assistant Director of Nursing Employee E3 at the time of the observation confirmed that Resident R13's urine bag was lying on the floor.
Further observation of the second-floor unit conducted on August 14, 2023, from 9:23 a.m. to 10:30 a.m. during the tour of the facility revealed that Resident R42 was in her room, in bed, sleeping. Further observation revealed that Resident R42 had a approximately half full urine bag. Further, Resident R42's urine bag was lying on the floor.
Review of Resident R42's clinical record revealed that there was a physician's order for urinary foley catheter.
Interview with Assistant Director of Nursing Employee E3 at the time of the observation confirmed that Resident R13's urine bag was lying on the floor.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
Jun 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
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and interviews with staff, it was determined that the facility did no...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and interviews with staff, it was determined that the facility did not develop a comprehensive care plan related to wounds and hospice care for three of eight records reviewed (Residents R2, R4, R5).
Findings include:
Review of facility policy titled Care Plan, dated January 2023, revealed that the care plan will include .MD (physician) orders .[and] treatments . and Care plans will be updated timely and necessary revisions made.
Review of clinical documentation for Resident R2 revealed that she had been readmitted from the hospital on May 25, 2023. An admission nursing note from that day at 7:31 p.m. stated open area to sacrum measuring 2 cm [wide] x 2 cm [long] x 1.5 cm [deep] . hospice to evaluate.
Nursing note date May 26, 2023, at 1:30 p.m. stated, hospice in today to assess. Another note from that day at 11:12 p.m. stated Resident's skin is noted with wound/skin breakdown .treatment administered daily. A nursing note from May 27, 2023, at 2:29 p.m. stated, resident currently on hospice.
Review of physician orders for Resident R2 revealed an order for Santyl Ointment 250 unit/gm (Collagenase) Apply to sacrum every evening shift for wound care, dated June 1, 2023 (Santyl is a medication which aids in the removal of dead tissue from a wound). Continued review revealed two physician orders dated June 6, 2023, which stated, Cleanse Sacrum with acetic acid (a disinfectant), pat dry, apply/pack wound with Santyl along with a moistened soaked gauze, cover with foam dressing, one scheduled for every evening shift for wound care, and one scheduled as needed for soilage. Additional review revealed a physician order of Hospice Eval and Treat dated May 25, 2023.
Review of the care plan for Resident R2 revealed that no care plan had been developed for either Hospice care or wound care.
Review of clinical documentation for Resident R4 revealed that he was admitted to the facility on [DATE]. An admission assessment note dated that day at 10:46 p.m. stated open area to left heel measuring 2cm [wide] x 2 cm [long] x 0.1cm [deep].
Review of physician orders for Resident R4 revealed on order for Wound Care [L (left) Achilles]: Cleanse with NSS (normal saline solution), cover with Adaptic, gauze, wrap with Kling every day shift for wound care, dated June 5, 2023.
Review of the care plan for Resident R4 revealed that no care plan had been developed his wound care.
Review of clinical documentation for Resident R5 revealed a physician order was entered for Cleanse Coccyx with Acetic acid 0.255 solution, pat dry, apply Medi-honey then mix calazime (a skin protectant) with Nystatin (a medication for fungal infections) together and apply to peri-wound (the area around a wound). Cover foam dressing. every evening shift for Wound Care dated June 9, 2023.
Review of the care plan for Resident R5 revealed that no care plan had been developed her wound care.
Interview with the Director of Nursing on June 13, 2023, at 12:30 p.m. confirmed that the above care areas for these residents should have been included in the person-centered care plans but were not.
28 Pa. Code 211.11(d) Resident care plan.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on review of facility policy, clinical record review and interview with staff, it was determined that the facility did not maintain complete and accurate clinical records for seven of eight clin...
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Based on review of facility policy, clinical record review and interview with staff, it was determined that the facility did not maintain complete and accurate clinical records for seven of eight clinical records reviewed (R1, R2, R3, R4, R6, R7, R8).
Findings include:
Review of facility policy titled Skin & Wound Care, dated January 2023, revealed that a complete skin assessment is to be done .weekly on shower/bath days, and that documentation of such will be monitored weekly for completion .
Review of documentation from April, May and June 2023 for Residents R1, R2, R3, R4, R6, R7, R8 revealed the following weekly skin assessment documentation was not completed with no documentation of resident refusal:
R1 did not have weekly skin assessment documentation completed on April 17, May 22, June 5, and June 12, 2023.
R2 did not have weekly skin assessment documentation completed on May 12, May 19, and June 9, 2023.
R3 did not have weekly skin assessment documentation completed on April 11, and June 6, 2023.
R4 did not have weekly skin assessment documentation completed on June 12, 2023.
R6 did not have weekly skin assessment documentation completed on June 6, 2023.
R7 did not have weekly skin assessment documentation completed on May 17, and May 24, 2023.
R8 did not have weekly skin assessment documentation completed on April 16, May 10, and May 21, 2023.
Interview with the Director of Nursing at 12:40 p.m. on June 13, 2023 confirmed the above findings were accurate and revealed that incomplete documentation of skin checks and resident refusals is an ongoing issue.
28 Pa. Code 211.12(c) Nursing service
28 Pa. Code 211.12(d)(1) Nursing service
28 Pa. Code 211.12(d)(2) Nursing service
28 Pa. Code 211.12 (d)(5) Nursing service
Mar 2023
2 deficiencies
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
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
Based on review of facility policy, review of clinical records, review of facility documentation and resident interview, it was determined that the facility failed to ensure that Resident R12 was free...
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Based on review of facility policy, review of clinical records, review of facility documentation and resident interview, it was determined that the facility failed to ensure that Resident R12 was free from resident abuse, which resulted in physical and psychosocial harm to Resident R12 who sustained bruise to right posterior upper extremity and emotional anguish for one of 12 residents reviewed. (Resident R12)
Findings include:
Review of facility policy title Abuse, Neglect and Exploitation last reviewed January 2023 revealed that abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Verbal abuse means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Under 'Resident protection after alleged abuse, neglect, and exploitation' - facility is to make efforts to protect all residents after alleged abuse as well as protection of staff and/or residents from retaliation.
Review of R12's clinical record revealed the diagnoses of cerebral infarction (stroke), dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder (mental disorder characterized by low moods and loss in pleasurable activities), unsteadiness on feet, muscle wasting and atrophy, encephalopathy (disease of brain that alters function and structure).
Review of nursing notes from February 25, 2023 at 4:15 pm, revealed resident was observed to have a bruise on right upper extremity (RUE) which was reported by Resident R12's husband to nursing assistant. Upon assessment resident stated, I asked the CNA (nurse aide) to change my diaper .she was upset with me because I wet the bed .the CNA threw me around in the bed and locked me in the bathroom for an hour. PRN (as needed) Tylenol administered to patient for complaint of pain to RUE. Upon full body assessment, this nurse noted two scratches (2cm L (length) x 0.5 cm W (width)) to right shoulder, a yellow bruise to left posterior LUE (2cm L x 3 cm), and fresh red bruise to right Posterior UE (8 cm L x 9 cm W). + AROM (active range of motion).
Review of R12's 'weekly skin checks' from February 25, 2023, at 4:48 pm revealed fresh red bruise to right Posterior UE (upper extremity) (8 cm L x 9 cm W).
Review of Resident R12's psychological evaluation on February 28, 2023, revealed that resident was seen for follow up supportive/life review therapy/behavioral management session per facility request due to resident making allegations of verbal abuse by a nursing staff member. Patient was alert, recognized clinician, and engaged well in interview process. She became tearful as she relayed details of incident with what she described as a nurse, African-American, with blonde braids. She reported that the staff member called her, a pig and a slob,because she had wet her bed, and threw me around in bed, and locked me in the bathroom. when asked how a staff member could lock her in the bathroom, which has no locks she stated, I don't know. I just know I couldn't get the door open.Patient currently presents with mild, ongoing depression and tearfulness. Patient's allegations discussed with
DON (Director of Nursing) who reported the aide was from an agency, she has already been reported, and is not allowed to return to this facility. Patient reports ongoing symptoms of depression, primarily associated with loss of two of her children. Will follow up next week to assess capacity to retain information across sessions.
Interview with Resident R12 on March 27, 2023, at 10:47 a.m. revealed I wet the bed, I was locked in bathroom for an hour, my wheelchair got stuck and she wouldn't help me out of bathroom she stripped my bed and threw me around in bed, she was abusive, mean, cruel. When asked if resident has been having any concerns regarding treatment from staff since incident on February 25, 2023, resident stated, I wouldn't name any names, I don't feel safe, I need assistance with toileting and I am scared they won't take me to the bathroom anymore, I am scared I will get locked in bathroom again. Resident was tearful during interview.
Review of facility's investigation report completed on February 27, 2023, revealed that on February 25, 2023, at 8:30 a.m., assigned nursing assistant, Employee E12 to R12 was verbally abusive to the resident by stating I will smack you in your *F** face with that diaper. When addressed by charge nurse, nursing assistant stated, I know what I said, I said what I said.
Further review of the facility investigation revealed a written statement provided by nursing assistant on duty who confirmed I heard the CNA who was taking care of [Resident R12] telling her to shut the *F*** up before I smack you in the face with these diapers.
Review of the facility investigation submitted to the Department of Health on February 28, 2023, revealed that the facility substantiated that Resident R12 was verbally abused by nursing aide, Employee E12.
The facility failed to ensure that Resident R12 was free from resident abuse, which resulted in actual harm to Resident R12, who sustained bruise to right posterior upper extremity and emotional anguish.
483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition
28 Pa. Code 201.29(j) Resident rights
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 211.12(d)(1) Nursing services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0742
(Tag F0742)
Could have caused harm · This affected 1 resident
Based on review of facility policy, review of clinical records, review of facility documentation and resident interview, it was determined that the facility failed to ensure that a resident who experi...
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Based on review of facility policy, review of clinical records, review of facility documentation and resident interview, it was determined that the facility failed to ensure that a resident who experienced physical abuse and emotional anguish was provided with psychological services for one of 12 residents reviewed. (Resident R12)
Findings include:
Review of R12's clinical record revealed the diagnoses of cerebral infarction (stroke), dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, major depressive disorder (mental disorder characterized by low moods and loss in pleasurable activities), unsteadiness on feet, muscle wasting and atrophy, encephalopathy (disease of brain that alters function and structure).
Review of nursing notes from February 25, 2023 at 4:15 pm, revealed resident was observed to have a bruise on right upper extremity (RUE) which was reported by Resident R12's husband to nursing assistant. Upon assessment resident stated, I asked the CNA (nurse aide) to change my diaper .she was upset with me because I wet the bed .the CNA threw me around in the bed and locked me in the bathroom for an hour. PRN (as needed) Tylenol administered to patient for complaint of pain to RUE. Upon full body assessment, this nurse noted two scratches (2cm L (length) x 0.5 cm W (width)) to right shoulder, a yellow bruise to left posterior LUE (2cm L x 3 cm), and fresh red bruise to right Posterior UE (8 cm L x 9 cm W). + AROM (active range of motion).
Review of R12's 'weekly skin checks' from February 25, 2023, at 4:48 pm revealed fresh red bruise to right Posterior UE (upper extremity) (8 cm L x 9 cm W).
Interview with Resident R12 on March 27, 2023, at 10:47 a.m. revealed I wet the bed, I was locked in bathroom for an hour, my wheelchair got stuck and she wouldn't help me out of bathroom she stripped my bed and threw me around in bed, she was abusive, mean, cruel. When asked if resident has been having any concerns regarding treatment from staff since incident on February 25, 2023, resident stated, I wouldn't name any names, I don't feel safe, I need assistance with toileting and I am scared they won't take me to the bathroom anymore, I am scared I will get locked in bathroom again. Resident was tearful during interview.
Review of facility's investigation report completed on February 27, 2023, revealed that on February 25, 2023, at 8:30 a.m., assigned nursing assistant, Employee E12 to R12 was verbally abusive to the resident by stating I will smack you in your *F** face with that diaper. When addressed by charge nurse, nursing assistant stated, I know what I said, I said what I said.
Further review of the facility investigation revealed a written statement provided by nursing assistant on duty who confirmed I heard the CNA who was taking care of [Resident R12] telling her to shut the *F*** up before I smack you in the face with these diapers.
Review of Resident R12's psychological evaluation on February 28, 2023, revealed that resident was seen for follow up supportive/life review therapy/behavioral management session per facility request due to resident making allegations of verbal abuse by a nursing staff member. Patient was alert, recognized clinician, and engaged well in interview process. She became tearful as she relayed details of incident with what she described as a nurse, African-American, with blonde braids. She reported that the staff member called her, a pig and a slob,because she had wet her bed, and threw me around in bed, and locked me in the bathroom. when asked how a staff member could lock her in the bathroom, which has no locks she stated, I don't know. I just know I couldn't get the door open.Patient currently presents with mild, ongoing depression and tearfulness. Patient's allegations discussed with
DON (Director of Nursing) who reported the aide was from an agency, she has already been reported, and is not allowed to return to this facility. Patient reports ongoing symptoms of depression, primarily associated with loss of two of her children. Will follow up next week to assess capacity to retain information across sessions.
Continued review of Resident R12's clinical record revealed no documented evidence that psychological services continue since the initial psychological evaluation on February 28, 2023.
Interview with the Director of Nursing on March 27, 2023 at 3:00 p.m. confirmed that no further psychological services were provided to Resident R12 following the abuse incident.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(c) Resident care policies
Dec 2022
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, observations, staff interview, and review of manufacturers' guid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, review of clinical records, observations, staff interview, and review of manufacturers' guidelines, it was determined that the facility failed to monitor and implement nutrition interventions consistent with the resident's assessment for one of four reviewed (Resident R1).
Findings include:
Review of Resident R1's admission Minimum Data Set (MDS - standardized resident assessment and care screening) dated November 20, 2022, revealed the resident was admitted to the facility on [DATE], and had diagnoses of malnutrition (occurs when the body does not get enough nutrients), muscle wasting, dysphagia (difficulty swallowing), stage four sacral pressure ulcer, diabetes mellitus (failure of the body to produce insulin), heart failure (when the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (group of diseases that blocks airflow and makes it difficult to breathe), and gastrostomy (surgical opening into the stomach for nutritional support).
Continued review of the MDS assessment section title 'Swallowing/Nutritional Status revealed Resident R1 received 51% or more of calories, and 501 cc/day or more of fluid intake through tube feeding (also known as enteral nutrition - way of delivering nutrition via a tube directly to your stomach) while a resident.
Review of section title Skin Conditions revealed Resident R1 had a stage four pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) present on admission. Nutrition and hydration was indicated as an intervention to manage skin problems.
Review of Resident R1's comprehensive care plan dated November 14, 2022, revealed the resident required a tube feeding related to dysphagia.
Continued review of the comprehensive care plan dated November 15, 2022 revealed Resident R1 was at risk for protein/energy malnutrition related to comorbidities causing need for increased calorie and protein needs as evidenced by muscle wasting and the need for tube feeding.
Review of Resident R1's physician order dated November 14, 2022, revealed the resident was ordered Glucerna 1.2 390 milliliters (ml) every 6 hours, providing a total of 1560 ml total volume of formula.
Review of Resident R1's nutrition admission assessment dated [DATE], by Registered Dietitian, Employee E8, revealed the resident had an NPO (nothing by mouth) diet and was dependent on the tube feeding to meet nutrition and hydration needs.
Continued review of Resident R1's nutrition assessment revealed the resident was ordered tube feeding formula Glucerna 1.2 (calorically dense specialized formula for people with diabetes - provides 1.2 calories (kcal) per milliliter) which the dietitian assessed as providing a total of 1560 ml, 1872 calories and 93.6 grams of protein per day. The Registered Dietitian determined that the tube feeding was meeting 100% of the resident's assessed nutrient needs and recommended the tube-feeding be continued as ordered to meet goals for weight maintenance and improved skin integrity.
Review of Resident R1's physician order audit summary revealed the physician order for Glucerna 1.2 390 ml every 6 hours was revised on November 25, 2022, and November 30, 2022, by Licensed Nurse, Employee E6, with supplemental directions to substitute with Glytrol 1kcal/mL (specialized formula for people with diabetes) if Glucerna 1.2 is unavailable.
Further review of Resident R1's clinical record revealed a nursing progress note dated December 11, 2022, by licensed nurse, Employee E5, that tube feeding formulas Glucerna 1.2 and Glytrol were unavailable and new orders were received [by the physician] to substitute with Glucerna [Glucerna 1.0 - provides 1kcal/ml].
Review of Resident R1's physician order, order date December 11, 2022, revealed to give Glucerna [1.0] as substitute for Glucerna 1.2 bolus feedings.
Review of Resident R1's clinical record revealed a follow-up note by the Registered Dietitian, Employee E8, on December 13, 2022, and indicated the tube-feeding should be meeting resident [nutrition] needs at 1872 calories per day.
Review of manufacturers' nutrition facts for each formula revealed that 1560 ml of Glytrol 1kcal/ml and Glucerna 1.0 would not provide an equivalent amount of protein and calories compared to Glucerna 1.2. Manufacturer guidelines revealed that Glucerna 1.2 had higher calorie and protein content.
Review of Resident R1's entire clinical record revealed no documented evidence that the dietitian reassessed the frequency and volume of the tube-feeding with the substituted tube-feeding formulas.
Observations on December 19, 2022, at 12:05 p.m. of the medication storage room on the first-floor nursing unit with Nursing Home Administrator, Employee E1, and Registered Dietitian, Employee E2, confirmed that Glucerna 1.0 and Glucerna 1.2 were unavailable.
Interview and observation at 12:10 p.m. with Licensed Nurse, Employee E7, revealed tube-feeding formula Glytrol 1.0 was available and prepped for Resident R1's feeding.
Interview on December 19, 2022, at 12:13 p.m. with Registered Dietitian, Employee E8, confirmed that Glytrol and Glucerna 1.0 were not comparable protein and calorie substitutions for Glucerna 1.2 at 390 ml bolus feeds every 6 hours. Employee E8 reported that the total volume of formula would need to be increased to meet the same calorie and protein content that the Glucerna 1.2 provided.
Further interview with the Registered Dietitian on December 19, 2022 at 12:57 p.m. revealed the Dietitian was not consulted when the tube-feeding formula was substituted with Glytrol 1.0 or Glucerna 1.0.
Interview with Central Supply, Employee E9, on December 19, 2022, at 1:50 p.m. revealed the Glucerna formula (1.0 and 1.2) have been unavailable for ordering for at least two months due to manufacturer backorder. Employee E9 reported Glytrol has been ordered as a substitute for Glucerna 1.0 and Glucerna 1.2 and that substitutions were communicated with the Registered Dietitian.
28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 211.6 (d) Dietary services
28 Pa. Code 211.12 (c)(5) Nursing Services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on review of facility policy, observation, staff interviews and review of manufacturers' guidelines, it was determined that the facility failed to ensure that all drugs and biologicals used in t...
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Based on review of facility policy, observation, staff interviews and review of manufacturers' guidelines, it was determined that the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards of practice for two of five medication carts observed (Second Floor Nursing Unit Cart 1 and Cart 2).
Findings include:
Review of facility policy Injectable Insulin Storage & Use revealed before opening, all unused vials of insulin should be stored in a refrigerator. Upon opening, vials of insulin are to be dated and stored away from direct heat and light and kept as cool as possible for up to 28 days.
Review of manufacturer's guidelines for Humalog Insulin (insulin lispro) (medication used to treat high blood sugar levels) revealed that Humalog must be discarded 28 days after opening.
Review of manufacturer's guidelines for Novolog Insulin (insulin aspart) revealed that the medication must be discarded 28 days after opening.
Observations on December 19, 2022, at 10:58 a.m. on the second floor nursing unit of Cart 1 medication cart with Licensed Nurse, Employee E3, revealed two opened vials of insulin aspart with no expiration date or open date.
Further observations at 11:03 a.m. on the second floor nursing unit of Cart 2 medication cart with licensed nurse, Employee E4, revealed an insulin lispro pen that had an open date of 10/6/2022.
28 Pa. Code 211.12(c) Nursing Services
28 Pa. Code 211.12(d)(1)(5) Nursing Services
28 Pa. Code 211.9(a)(1) Pharmacy Services
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 38% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
- • 40 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $29,073 in fines. Higher than 94% of Pennsylvania facilities, suggesting repeated compliance issues.
Bottom line: Mixed indicators with Trust Score of 60/100. Visit in person and ask pointed questions.
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About This Facility
What is River'S Edge Rehabilitation & Healthcare Center's CMS Rating?
CMS assigns RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Pennsylvania, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is River'S Edge Rehabilitation & Healthcare Center Staffed?
CMS rates RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 38%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at River'S Edge Rehabilitation & Healthcare Center?
State health inspectors documented 40 deficiencies at RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER during 2022 to 2025. These included: 1 that caused actual resident harm and 39 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates River'S Edge Rehabilitation & Healthcare Center?
RIVER'S EDGE REHABILITATION & HEALTHCARE 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 PARAMOUNT CARE CENTERS, a chain that manages multiple nursing homes. With 120 certified beds and approximately 113 residents (about 94% occupancy), it is a mid-sized facility located in PHILADELPHIA, Pennsylvania.
How Does River'S Edge Rehabilitation & Healthcare Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER's overall rating (4 stars) is above the state average of 3.0, staff turnover (38%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting River'S Edge Rehabilitation & Healthcare Center?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is River'S Edge Rehabilitation & Healthcare Center Safe?
Based on CMS inspection data, RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at River'S Edge Rehabilitation & Healthcare Center Stick Around?
RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER has a staff turnover rate of 38%, which is about average for Pennsylvania nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was River'S Edge Rehabilitation & Healthcare Center Ever Fined?
RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER has been fined $29,073 across 5 penalty actions. This is below the Pennsylvania average of $33,370. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is River'S Edge Rehabilitation & Healthcare Center on Any Federal Watch List?
RIVER'S EDGE REHABILITATION & HEALTHCARE 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.