CORNER VIEW NURSING AND REHABILITATION CENTER
For profit - Corporation
187 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
0/100
#546 of 653 in PA
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Corner View Nursing and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the facility's care and operations. Ranking #546 out of 653 in Pennsylvania places it in the bottom half of nursing homes in the state, and #36 out of 52 in Allegheny County suggests that there are better local options available. The facility's performance is worsening, as the number of issues identified rose from 14 in 2024 to 27 in 2025. Staffing is somewhat better, with a rating of 3 out of 5 stars and a low turnover rate of 0%, but RN coverage is below average compared to 80% of facilities in Pennsylvania, which raises concerns about the level of skilled oversight. Additionally, the facility has faced troubling incidents, including a critical failure to protect residents from sexual abuse and unsafe kitchen conditions that could lead to food contamination, highlighting serious risks to resident safety and wellbeing.
- Trust Score
- F
- In Pennsylvania
- #546/653
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- $137,886 in fines. Lower than most Pennsylvania facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for Pennsylvania. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 51 deficiencies on record. Higher than average. Multiple issues found across inspections.
0/100
Bottom 17%
Review needed
14 → 27 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 14 issues
2025: 27 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Pennsylvania average (3.0)
Significant quality concerns identified by CMS
Federal Fines: $137,886
Well above median ($33,413)
Significant penalties indicating serious issues
The Ugly 51 deficiencies on record
1 life-threatening
Jul 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview it was determined that the facility failed to provide medical record access for one of seven residents ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview it was determined that the facility failed to provide medical record access for one of seven residents (Resident R1).Findings include:Facility documentation indicated Resident R1 was admitted on [DATE].Review of Resident R1's MDS (minimum data set a periodic assessment of basic needs) dated 12/11/24, revealed diagnoses of diabetes mellites, end stage renal disease and atherosclerosis of the arteries (disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls). Review of facility provided documentation indicated a request for medical records 4/22/25 by a law firm. Resident R1's daughter, who was her emergency contact was listed on her death certificate. During an interview on 7/23/25, at 3:30 p.m., the Nursing Home Administrator could not provide documentation that the medical records were sent and that the initial request was made several months ago.28 Pa. Code 201.29(a)Resident rights.
Apr 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on review of facility policy, observations and staff interviews it was determined the facility failed to ensure comfortable air temperature levels were provided for 22 of 25 residents (Resident ...
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Based on review of facility policy, observations and staff interviews it was determined the facility failed to ensure comfortable air temperature levels were provided for 22 of 25 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, and R22).
Findings include:
Review of the facility policy Homelike Environment dated 2/3/25, indicated the facility will provide residents with a safe, clean, comfortable, and homelike environment. The policy further stated the facility staff and management maximizes, to the extent possible comfortable and safe temperatures (71°F - 81°Fahrenheit).
Review of Title 42 Code of Federal Regulations §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.
During an interview on 4/8/25, at approximately 3:15 p.m. Maintenance Employee E1 stated the boiler (a closed tank where water is heated under pressure, and then used for hot water or heating a building) stopped functioning on 4/5/25. At this time, temperature logs since the boiler malfunction were requested.
During an interview on 4/8/25, at 3:40 p.m. Maintenance Employee E1 confirmed the boiler went down Saturday (4/5/25), and was repaired late this morning (4/8/25).
During observations of resident area temperatures on 4/8/25, Maintenance Employee E1 received a phone call from Maintenance Employee E2, which he answered on Speakerphone in the presence of the surveyor and the Nursing Home Administrator (NHA). During this phone call, Maintenance Employee E2 stated the temperatures on the log were really low, and that's why they are here. Maintenance Employee E2 asked if he should make new temperature records.
During an interview of 4/8/25, at 3:56 p.m. Maintenance Employee E2 was asked when the boiler stopped functioning, and he stated, I believe it was Sunday afternoon (4/6/25). When asked when he started monitoring facility temperatures, Maintenance Employee E2 stated, 6 am Monday morning. During this interview, Maintenance Employee E2 stated that he felt the low temperatures were inaccurate. When asked why if he felt they were inaccurate, he did not act upon them, he was unable to provide an answer.
During a confidential interview on 4/8/25, at 4:10 p.m. the resident stated, The boiler is broken. It's cold, but you didn't hear that from me.
During an interview on 4/8/25, at 4:11 p.m. Resident R1 stated, It was cold this weekend.
During an interview on 4/8/25, at 4:15 p.m. when asked if it was cold in the facility over the weekend, Resident R2 stated, A little bit.
During an interview on 4/8/25, at 4:17 p.m. when asked if it was cold in the facility over the weekend, Resident R3 stated, Yes.
During an interview on 4/8/25, at 4:24 p.m. when asked if it was cold in the facility over the weekend, Resident R4 stated, Yes, I had to put this on. At this time, Resident R4 displayed a gray hooded sweatshirt.
During an interview on 4/8/25, at 4:25 p.m. when asked if it was cold in the facility over the weekend, Resident R5 stated, It was cold.
During an interview on 4/8/25, at 4:32 p.m. when asked if it was cold in the facility over the weekend, Resident R6 stated, It's always cold here.
Review of facility provided temperature logs on 4/8/25, at 4:45 p.m. revealed no temperatures collected on 4/5/25, and 4/6/25. Once daily temperatures were collected on 4/4/25 (Friday), and 4/8/25 (Monday).
During an interview on 4/8/25, at 4:46 p.m. the NHA confirmed he was not made aware of the boiler malfunction until 4/6/25, at 4:36 p.m.
Review of facility submitted information dated 4/9/25, indicated that on 4/6/25, at approximately 1:00 p.m. Maintenance Employee E1 identified the boiler was not functional. Maintenance Employee E1 to repair the boiler without success. Maintenance Employee E1 reported to the Maintenance Employee E2 that boiler was down. Maintenance Employee E2 notified the Nursing Home Administrator. The Nursing Home Administrator reported to the regional team and gave direction to have a vendor come in to repair the boiler. Maintenance Employee E2 reported that the Center was at a home like environment with the temperature at the 71-to-81-degree threshold.
Review of the facility provided temperature log for 4/7/25, of the 18 resident areas monitored, 16 were below 71°F:
Resident R2's room: 67°F
Resident R7 and R8's room: 69°F
Resident R9's room: 62°F
Resident R10's room: 65°F
Resident R11 and R12's room: 67°F
Resident R13 and R14's room: 60°F
Resident R15 and R16's room: 70°F
Resident R17 and R18's room: 57°F
Resident R19 and R20's room: 68°F
Resident R21 and R22's room: 63°F
Vacant resident room: 63°F
3 East Central Bath: 67°F
4 East Central Bath: 69°F
5 East Central Bath: 65°F
5 [NAME] Central Bath: 66°F
6 East Central Bath: 67°F
During an interview on 4/8/25, at approximately 5:00 p.m. the Nursing Home Administrator confirmed the facility failed to ensure comfortable air temperature levels were provided for 22 of 25 residents.
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 205.61(a) Heating and Electrical Requirements
Apr 2025
3 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility documentation, clinical records, and staff interviews, it was determined that the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, facility documentation, clinical records, and staff interviews, it was determined that the facility failed to protect Resident R3 with severe cognitive impairment from unwanted/non-consensual sexual contact by Resident R1 who had a history of sexually inappropriate behavior, including an unsolicited sexual contact with Resident R2 on February 18, 2025. This failure resulted in an Immediate Jeopardy situation when Resident R1 was found naked on top of Resident R3. (Resident R1, R2 and R3)
Findings Include:
Review of facility policy Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2/3/25, indicated that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.
Review of the facility policy Care Plans, Comprehensive Person-Centered, dated 2/3/25, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The interdisciplinary team reviews and updates the care plan:
a. when there has been a significant change in the resident's condition.
b. when the desired outcome is not met.
c. when the resident has been readmitted to the facility from a hospital stay; and
d. at least quarterly, in conjunction with the required quarterly assessment.
Review of Resident R1's clinical record indicated that he was admitted to the facility on [DATE].
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of dementia (a decline in cognitive function that interferes with daily life), mood disorder (mental health condition that primarily affect emotional states), and paranoid schizophrenia (subtype of schizophrenia characterized by persistent paranoid delusions). Further review of MDS Section C- Cognitive Patterns, C0500 BIMS Summary Score indicate Resident R1 scored an 11, moderately impaired.
Review of Resident R1's clinical progress note dated 2/18/25, at 10:46 a.m., stated a Nurse Aide (NA) reported that Resident R1 was in his room with female Resident R2. Evaluated situation, Resident R1 naked, with female Resident R2 naked from waist down, call placed to Supervisor and Administration.
Review of facility documentation submitted 2/18/25, indicated that Resident R1 was seen sitting at bedside naked with Resident R2 in his bed naked. Staff told Resident R2 its time to get up, and Resident R1 became upset and told staff she is a grown women and can do what she wants. Resident R2 taken back to room, skin assessment completed with no injury notes, patient unable to recall or report pain. Resident R1 was placed on one to one.
Review of facility documentation submitted witness statement by Nurse Aide (NA) Employee E2 dated 2/18/25, NA Employee E2 was looking for Resident R2 and when Employee E2 found her, she was in a males (R1) room, laying on his bed with her vagina visible and the gentleman (R1) attempting to cover her up with his blanket as to why he was naked on the side of the bed. Employee E2 got her (R2) up from his bed and reported incident to the nurse on the floor and she contacted the Director of Nursing (DON) and the Administrator (NHA).
Review of Resident R1's clinical physician progress note dated 2/19/25, at 2:41 p.m., stated an immediate request to see patient because of an unwanted sexual encounter with another resident who is older and much more cognitively impaired. Patient has now become very agitated and aggressive when confronted; that he has been very mad all day and has been refusing his medications and meals. Patient is alert and oriented times two, and was in denial that any of this had happened; that all of the things staff were saying he did were not true; agreed that their allegations were bad things, but was adamant that he didn't do it and wouldn't ever do it again even if he did.
Review of Resident R1's care plan on 4/2/25, indicated that on 2/18/25, his care plan was updated to include a problem focused on behavior due to sexual, combative and aggression towards staff and other residents; Care plan goal that Resident R1 will have fewer episodes of sexual, combative, aggression weekly. Further review of the care plan indicated that 15-minute checks for related sexual behavior was initiated on 2/18/25, and resolved 3/20/25. Further review of care plan failed to indicate that the facility developed appropriate care plan interventions to prevent further sexually inappropriate behaviors, specifically addressing supervision of Resident R1 and the safety of other residents from an alleged perpetrator of sexual abuse.
Review of facility provided documentation revealed Resident Observation q 15 Minute Checks Documentation was initiated 10:00 a.m., on 2/18/25, and was stopped at 10:45 a.m., on 2/19/25.
Interview conducted on 4/1/25, at 3:30 p.m., with [NAME] President of Clinical Operations (VP of Ops) Employee E1 revealed that every (q) 15 minute checks were stopped once Resident R1 was seen and evaluated by Psychiatric physician for follow-up which occurred 2/19/25, at 10:15 a.m. VP of Ops Employee E1 confirmed that facility failed to develop interventions after 2/18/25, event, that continually monitored and supervised Resident R1 behavior and actions towards others, to include cognitively impaired residents residing on unit.
Review of Resident R2's clinical record indicated that she was admitted to the facility on [DATE].
Review of Resident R2's Minimum Data Set, dated [DATE], indicated diagnoses of Alzheimer's disease (chronic neurodegenerative condition that primarily affects memory, thinking, and behavior), dementia, and major depressive disorder (mental disorder characterized by persistent low mood, loss of interest or pleasure in activities, and a range of emotional and physical problems). Further review of MDS Section B- Hearing, Speech, and Vision, B0700 Makes Self Understood is coded 3, rarely/never understood; B0800 Ability to Understand Others is coded 3, rarely/never understands; Section C - Cognitive Patterns, C1000 Cognitive Skills for Daily Decision-Making is coded 3, severely impaired - never/rarely makes decisions. Section E - Behavior, E0900 Wandering - Presence and Frequency was coded 1, indicating behavior of this type occurred 1 to 3 days.
Review of Resident R2's clinical progress note dated 2/18/25, at 10:54 a.m., stated Resident R2 was found in a male resident's room in bed, naked from the waist down. Evaluation done, no apparent injures, old scratches noted, Supervisor and ADON made aware.
Review of Resident R2's clinical physician progress note dated 2/19/25, at 2:42 p.m., stated that today staff request for me to see patient; reported that she had a suspected sexual encounter with another resident who is much younger and much more cognitively intact.
Review of facility submitted documentation on 2/18/25, indicated that female Resident R2 was evaluated at the hospital and placed on another unit. Family refused rape kit at hospital.
Review of Resident R2's care plan dated 6/21/21, revised on 3/26/23, indicated that resident has impaired cognitive function/dementia or impaired thought processes regards to Alzheimer's, dementia. Intervention dated 6/21/21, included to cue, reorient, and supervise as needed. Further review of care plan dated 1/7/21, revised on 9/13/23, indicated that Resident R2 is an elopement risk/wanderer. Intervention dated 1/7/21, included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or books.
Review of Resident R2's current care plan failed to indicate that her care and services was reviewed, updated, or revised to address alleged sexual abuse by another resident which occurred 2/18/25.
Further review of Resident R1's clinical progress note dated 3/20/25, at 7:32 a.m., stated Resident R1 was found in his room on top of another female Resident R3. Orders received to send Resident R1 out to the hospital for further treatment and evaluation.
Further review of Resident R1's clinical progress note dated 3/20/25, at 7:56 a.m., stated Resident R1 was found to have female Resident R3 in his room. She (R3) was caught in a sexual position under resident (R1).
Review of Resident R3's clinical record indicated that she was admitted to the facility on [DATE].
Review of Resident R3's Minimum Data Set, dated [DATE], indicated diagnoses of dementia, major depressive disorder, and adult failure to thrive. Further review of MDS Section C - Cognitive Patterns, C0100 Should Brief Interview for Mental Status be conducted was coded 1, indicating that yes interview should be conducted. Section C0500 was coded 99, indicating Resident R3 was unable to complete interview. Section C1000, Cognitive Skills for Daily Decision Making was coded 3, indicating that Resident R3's cognition is Severely impaired - never/rarely made decisions.
Review of Resident R3's clinical progress note dated 3/20/25, at 6:04 a.m., stated resident (R3) was found across the hall in another resident's (R1) room. Resident (R3) was found by a Nurse Aide (NA) in a sexual position in resident's (R1) bed. She (R3) was encouraged to leave the room.
Further review of Resident R3's clinical progress note dated 3/20/25, at 7:04 a.m., stated NA on duty immediately informed me Resident R3 was found in a room lying on B bed, the resident (R1) from B bed lying on top of her (R3). Resident R3 to be sent out to the hospital for further treatment and evaluation.
Review of facility documentation submitted witness statement from NA Employee E3 dated 3/20/25, stated that Resident R3 was no longer in her bed when doing rounds, having just checked on her (R3) 15 minutes prior. Went to check in the male room (Resident R1's room) across the hall due to the fact that he had a situation in the past. Knocked on the door and witnessed the male resident (R1) on top of the female resident (R3). Resident R1 was told to get off of her (R3) and called for help. Resident R3 was taken to her room.
Review of facility documentation initially submitted on 3/20/25, indicated that hospital records from Resident R3's encounter on 3/20/25, that patient was unable to tolerate any swab or internal exam of orifices, and this was subsequently deferred. Patient was seen by our discharge planning team to help with possible change in residency or going home, but for now family is comfortable the patient going back to the nursing care facility. The reported assailant is no longer at facility. Patient was overall at her usual state of health and was discharged from our facility.
Review of Resident R3's care plan dated 3/1/25, revised 3/20/25, indicated that resident has a behavior problem attention seeks, flirtatious behavior, wanders in and out of other resident rooms regards to dementia, with goals for fewer episodes daily, and interventions to administer medications as ordered and monitor for side effects; anticipate and meet resident's needs; and caregivers to provide opportunity for positive interaction, attention: stop and talk with her as passing by.
The Director of Nursing (DON), the Nursing Home Administrator (NHA), and the VP of Ops Employee E1 were made aware that an Immediate Jeopardy situation existed for residents on 4/2/25, at 10:03 a.m. and an immediate action plan was requested.
On 4/2/25, at 10:03 a.m. the Immediate Jeopardy template was provided to the facility administration.
On 4/2/25, at 6:08 p.m. an acceptable Corrective Action Plan was received which included the following interventions:
Immediate Action:
Resident R1: was discharged to the hospital and will not return to the center.
Resident R2: was assessed by nursing for any adverse effects of the alleged event and found no harm.
Resident R2's responsible party and physician were contacted. Resident sent to acute care hospital for in depth evaluation. Resident returned to facility with medication and found to be at baseline. Psych consulted and assessment performed. Education and observations are ongoing to ensure residents are secure and safe.
Resident R3: was assessed for any adverse effects of the alleged event and found no harm. Resident R3's responsible party and physician were contacted Resident sent to acute care hospital for in depth evaluation. Resident returned to facility with medication and found to be at baseline. Psychosocial assessments performed with negative findings. Psychological services were consulted and assessment performed. Education and observations are ongoing to ensure residents are secure and safe.
Root cause analysis identified that facility failed to provided adequate supervision to the alleged perpetrator.
Actions taken to identify any residents with sexual behaviors:
House education done by 4/3/25, by DON/Designee provided to all staff reviewing identifying type of abuse, anonymous reporting and reporting abuse.
[NAME] law list check ran on all residents on 3/20/25, by DON/Designee. DON/Designee will audit all new admissions since 3/20/25, to ensure [NAME] law list checks were performed prior to admission. This will be completed by 4/3/2025.
The DON/Designee was educated by the VP of Clinical Services on 4/2/25, on the use of the Sexual Activity Scale and interventions for residents who are identified to be high risk.
The DON/Designee will perform sexual activity scale on all residents as a tool to determine if any other residents pose a risk of engaging in unwanted sexual behaviors by 4/3/25. Residents who score high risk on the sexual activity scale will have care plan and interventions updated as needed.
DON/Designee will perform Sexual Activity Scale tool on all new admissions and five random residents monthly times three months and as needed.
Policies on Abuse and Neglect were reviewed by the DON, NHA, and Medical Director and updated on 4/2/25.
Observation and audit findings will be reviewed at the facility's monthly quality assurance meeting.
Immediate Jeopardy was lifted on 4/3/25, at 3:04 p.m., and the abatement plan was verified as follows:
Immediate actions verified.
Resident interviews were reviewed, and it was verified that 159 of 159 residents were interviewed to determine whether they had knowledge of sexually inappropriate behaviors amongst residents, if they feel safe, and if they know how to report concerns.
Root cause analysis identified that facility failed to provide adequate supervision to the alleged perpetrator.
Facility identified 185 staff members from all departments. Staff interviews completed. 22 of 22 clinical staff members and 43 of 43 non-clinical staff interviewed in person and training was verified as completed and content understood. A total of 65 of 65 in-house staff present in facility were verified as trained. 100% of staff on-site have been verified as receiving abuse training.
129 staff members were verified as having received abuse training via in-person signatures.
Two of five staff members answered telephonic communication and verified that training was received and understood via phone; three of five were left voicemails to return call.
All staff unaccounted for at this time will receive and sign abuse education training prior to next scheduled shift.
Review of [NAME]'s Law check completed on 3/20/25, was verified for 163 of 163 residents. Review of new admissions from 3/20/25, verified that ten of ten residents [NAME]'s Law checks were completed.
Review of Clinical Education Services form verified that VP of Clinical Services completed education to the DON on the Sexual Activity Scale (SAS) tool and interventions for residents who are identified to be high risk on 4/2/25.
Sexual Activity Scale tool was completed as of 4/3/25, for 152 of 152 residents. There were no new residents identified as high risk.
Review of audit tool for future monitoring of Sexual Activity Scale tool completion confirmed.
Revised Abuse policy was verified as updated of 4/3/25. The change made to the policy Residents have the right to engage in sexual activity. However, anytime there is a reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse, including evaluating whether the resident has the capacity to consent to sexual activity.
Next facility QAPI meeting scheduled on April 16, 2025.
During an interview on 4/3/25, at 3:10 p.m., information was disseminated to the Nursing Home Administrator (NHA) and VP of Ops Employee E1 that the facility failed to protect Resident R3 with severe cognitive impairment from unwanted/non-consensual sexual contact by Resident R1 who had a history of sexually inappropriate behavior, including an unsolicited sexual contact with Resident R2 on February 18, 2025. This failure resulted in an Immediate Jeopardy situation when Resident R1 was found naked on top of Resident R3, and because this type of inappropriate, unwanted sexual contact would reasonably cause anyone to have psychosocial harm, it can be determined that the reasonable person in these residents' position would have experienced severe psychosocial harm- dehumanization, and humiliation- as a result of the sexual abuse. (Resident R2 and R3)
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10 (d) Resident care policies
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 F0657
(Tag F0657)
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 records, and staff interview, it was determined the facility failed to ensure that ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview, it was determined the facility failed to ensure that residents' comprehensive care plans were reviewed and revised as needed to accurately reflect their current needs and services required by two of three residents sampled (Residents R1, and R2).
Findings include:
Review of the facility policy Care Plans, Comprehensive Person-Centered, dated 2/3/25, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident. The interdisciplinary team reviews and updates the care plan:
a. when there has been a significant change in the resident's condition;
b. when the desired outcome is not met;
c. when the resident has been readmitted to the facility from a hospital stay; and
d. at least quarterly, in conjunction with the required quarterly assessment.
Review of Resident R1's clinical record indicated that he was admitted to the facility on [DATE].
Review of Resident R1's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated diagnoses of dementia (a decline in cognitive function that interferes with daily life), mood disorder (mental health condition that primarily affect emotional states), and paranoid schizophrenia (subtype of schizophrenia characterized by persistent paranoid delusions). Further review of MDS Section C- Cognitive Patterns, C0500 BIMS Summary Score indicate Resident R1 scored an 11, moderately impaired.
Review of Resident 1's clinical progress note dated 2/18/25, at 10:46 a.m., stated a Nurse Aide (NA) reported that resident [R1] was in his room with female resident. Evaluated situation, resident [R1] naked, with female resident naked from waist down, call placed to Supervisor and Administration.
Review of Resident R1's clinical physician progress note dated 2/19/25, at 2:41 p.m., stated an immediate request to see patient because of an unwanted sexual encounter with another resident who is older and much more cognitively impaired.
Review of Resident R1's care plan on 4/2/25, indicated that on 2/18/25, his care plan was updated to include a problem focused on behavior due to sexual, combative and aggression towards staff and other residents; Care plan goal that Resident R1 will have fewer episodes of sexual, combative, aggression weekly. Further review of the care plan failed to indicate that the facility developed appropriate care plan interventions to prevent further sexually inappropriate behaviors, specifically addressing supervision of Resident R1 and the safety of other residents from an alleged perpetrator of sexual abuse.
Review of Resident R2's clinical record indicated that she was admitted to the facility on [DATE].
Review of Resident R2's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/2/25, indicated diagnoses of Alzheimer's disease (chronic neurodegenerative condition that primarily affects memory, thinking, and behavior), dementia, and major depressive disorder (mental disorder characterized by persistent low mood, loss of interest or pleasure in activities, and a range of emotional and physical problems). Further review of MDS Section B- Hearing, Speech, and Vision, B0700 Makes Self Understood is coded 3, rarely/never understood; B0800 Ability to Understand Others is coded 3, rarely/never understands; Section C - Cognitive Patterns, C1000 Cognitive Skills for Daily Decision Making is coded 3, severely impaired - never/rarely makes decisions.
Review of Resident R2's clinical progress note dated 2/18/25, at 10:54 a.m., stated resident [R2] was found in a male residents room in bed, naked from the waist down. Evaluation done, no apparent injures, old scratches noted, Supervisor and ADON made aware.
Review of Resident R2's clinical physician progress note dated 2/19/25, at 2:42 p.m., stated that today staff request for me to see patient; reported that she had a suspected sexual encounter with another resident who is much younger and much more cognitively intact.
Review of Resident R2's current care plan failed to indicate that her care and services was reviewed, updated, or revised to address alleged sexual abuse by another resident.
During an interview on 4/3/25, at 3:10 p.m., the Nursing Home Administrator (NHA) and [NAME] President of Clinical Operations (VP of Clinical Ops) confirmed that the facility failed to ensure that residents' comprehensive care plans were reviewed and revised as needed to accurately reflect their current needs and services for two of three residents (Resident R1 and R2) after an alleged incident of sexual abuse.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.
CONCERN
(F)
📢 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
Administration
(Tag F0835)
Could have caused harm · This affected most or all residents
Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to ma...
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Based on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator and Director of Nursing did not effectively manage the facility to make certain that necessary care and services were provided to residents to prevent sexual abuse for 2 of 2 residents (Resident R2 and R3),
which created an immediate jeopardy situation for all 152 of 152 residents.
Findings include:
Review of CFR §483.70 Administration. A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.
The job description for the Nursing Home Administrator (NHA) specified the responsibility for overseeing the daily operation of the nursing facility, ensuring compliance with Pennsylvania state laws, Medicare/Medicaid, and federal regulations. This role involves managing staff, coordinating patients care, maintaining financial stability, and upholding the highest standards of resident care and safety.
The job description of the Director of Nursing (DON) specified the responsibility to plan, organize, develop and direct the overall operation of the Nursing Services Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern the facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times.
Based on findings in the report, the facility failed to protect Resident R1 and Resident R2 from sexual abuse, which placed the residents in Immediate Jeopardy. The NHA and the DON failed to fulfill their essential job duties to ensure the federal and state guidelines and regulations were followed.
During an interview on 4/3/25, at 3:10 p.m., the NHA and DON confirmed that they failed to effectively manage the facility to prevent sexual abuse for 2 of 2 residents (Resident R2 and R3).
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.
Feb 2025
22 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 F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and resident 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, observations, and resident and staff interviews, it was determined that the facility failed to determine the ability to safely self-administer medications for two of six residents reviewed (Resident R143, and R318).
Findings include:
Review of the facility's policy Self-Administration of Medication last reviewed 2/3/25, indicated residents have the right to self-administer medications if the interdisciplinary team has determined it is clinically appropriate and safe for the resident to do so. The staff and practitioner will document their findings and the choices of residents who are able to self-administer medications.
Review of the admission record indicated Resident R143 was admitted to the facility on [DATE].
Review of Resident R143's Minimum Data Set (MDS - a periodic assessment of care needs) dated 11/5/24, indicated the diagnoses of Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness), and schizophrenia (characterized by thoughts or experiences that seem out of touch with reality, disorganized speech or behaviors, and decreased participation in activities of daily living).
Review of Resident R143's physician orders dated 2/1/25, indicated lactulose (medication that treats liver disease) 30 mls (milliliters) twice daily for treatment of cirrhosis of the liver (diseased liver), and failed to indicate an order for self-administration of medications.
Review of Resident R143's care plan dated 1/14/24, indicated to give medications as ordered, and failed to include a goal or interventions for self-administration of medications.
Review of assessments indicated that an assessment to safely self-administer medications was not completed.
Observations of Resident R143's overbed table on 2/3/25, at 9:29 a.m. revealed a medication cup filled with a green liquid.
Interview on 2/3/24, at 9:45 a.m. Licensed Practical Nurse (LPN) Employee E7 confirmed the medication cup was Resident R143's lactulose.
Review of the admission record indicated Resident R318 was admitted to the facility on [DATE].
Review of Resident R318's MDS dated [DATE], indicated the diagnoses of high blood pressure, atrial fibrillation (irregular heart rhythm), and heart failure (heart doesn't pump blood as well as it should).
Review of Resident R318's physician orders dated 1/16/25, indicated albuterol (medication to assist in breathing) aerosol two puffs every four hours as needed for wheezing, and failed to indicate an order for self-administration of medications.
Review of Resident R318's care plan dated 1/22/25, indicated to give aerosol or bronchodilators (relaxes muscles in the airway making it easier to breathe) as ordered, and failed to include a goal or interventions for self-administration of medications.
Review of assessments indicated that an assessment to safely self-administer medications was not completed.
Observations of Resident R318's overbed table on 2/3/25, at 9:32 a.m. revealed an albuterol inhaler on resident's nightstand.
Interview on 2/3/24, at 9:45 a.m. Licensed Practical Nurse (LPN) Employee E7 confirmed the albuterol inhaler was sitting on resident's nightstand.
Interview on 2/3/25, at 2:00 p.m. the Director of Nursing, confirmed the facility failed to determine the ability to safely self-administer medications for two of six residents reviewed (Resident R143, and R318).
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(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
Investigate Abuse
(Tag F0610)
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 staff interview, it was determined that the facility failed to fu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of three residents (Resident R24).
Findings include:
Review of the facility policy Abuse Investigation and Reporting reviewed 1/15/24, indicated if an incident or suspected incident of resident abuse, mistreatment, neglect, or injury of unknown source is reported, the administrator will assign the investigation to an appropriate individual. The investigation must include interviews of any witnesses to the incident, the resident's roommate, family, and staff members on all shifts who have had contact with the resident during the period of the alleged incident. Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it.
Review of the facility policy Assessing Falls and Their Causes reviewed 1/15/24, indicated falls are a leading cause of morbidity and mortality among the elderly in nursing homes. The incident report form should be completed by the nursing supervisor on duty at the time and submitted to the Director of Nursing.
A review of the clinical record indicated Resident R24 was admitted to the facility on [DATE], and readmitted [DATE], with diagnoses that included high blood pressure, dislocation of right shoulder joint, and diabetes.
Review of Residents R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/11/24, indicated diagnoses were current. Section GG- Functional Abilities GG0170. Mobility indicated the resident was dependent with the ability to roll from lying on back to left and right side, and return to lying on back of bed.
A review of facility records indicated on 1/28/25, Resident R24 was turned on her side with an assist of one person, left unattended, and fell out of bed. The facility failed to provide evidence post-fall monitoring occurred as required. Resident R24 was found unresponsive on 1/29/25, and ceased to breathe at 5:41 a.m. The facility failed to investigate the incident to eliminate possible abuse or neglect. The facility failed to obtain any statements that were both signed and dated by the witnesses. No information was provided for Resident R24's roommate or LPN, Employee E5 who was the nurse assigned to her care from 11:00 p.m. on 1/28/25, until 7:00 a.m. on 1/29/25. The incident was not fully investigated to rule out abuse or neglect.
During an interview on 2/4/25, at 11:33 a.m. the Nursing Home Administrator confirmed Resident R24's incident was not fully investigated, and the facility failed to obtain statements that were both signed and dated by the witness.
28 Pa. Code: 201.149(a) Responsibility of licensee.
28 Pa. Code: 201.18(e)(1) Management.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, and clinical records, facility documents, as well as staff interviews, it was determined t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, and clinical records, facility documents, as well as staff interviews, it was determined that the facility failed to ensure documentation was timely entered for a resident after an unwitnessed fall occurred for one of three residents (Resident R24).
Findings include:
Review of the facility policy Charting and Documentation reviewed 1/15/24, indicated all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.
Review of the facility policy Change in a Resident's Condition or Status last reviewed 1/15/24, indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
Review of Residents R24's admission record indicated she was admitted on [DATE], and readmitted [DATE].
Review of Residents R24's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/11/24, indicated diagnoses of diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), renal insufficiency (condition where the kidneys lose the ability to remove waste and balance fluids), and dementia (a decline in cognitive functions such as memory, reasoning, and communication, significantly affecting daily life).
Review of Resident R24's incident report dated 1/28/25, at 6:00 p.m. completed by Registered Nurse, Employee E1 indicated Resident R24 had an unwitnessed fall.
Review of a late entry progress note entered by RN, Employee E1 on 1/29/25, at 5:51 a.m. effective 1/28/25, at 6:00 p.m. stated she was called to unit due the resident falling on floor. The nurse on the unit stated she was turned on her side for comfort to poop and rolled onto floor by accident. Resident denied pain, dizziness or injury. Denies hitting anything upon falling. Vitals stable within normal limits. Care plan to continue. The note was entered after the resident's time of death was called at 5:41 a.m.
Review of a late entry progress note entered by Licensed Practical Nurse, Employee E2 on 1/29/25, at 9:55 a.m. effective 1/29/25, at 9:39 a.m. stated this nurse was sitting at nurses' station when I heard someone yelling for help. Nurse Aide went in room, turned around and stated, resident is on the floor. This nurse went room and found resident laying on her left side parallel to left of bed. 3-11 Supervisor made aware. The note was entered after the resident's time of death was called at 5:41 a.m.
Review of a late entry progress note entered by RN, Employee E1 on 1/29/25, at 9:41 a.m. effective 1/28/25, at 6:00 p.m. stated RN called to floor by unit nurse for a report of resident falling onto floor. When RN arrived, resident was on the floor being assisted by two nurse aides with a hoyer lift back to bed. Fall was unwitnessed by staff. The note was entered after the resident's time of death was called at 5:41 a.m.
Review of a late entry progress note entered by LPN, Employee E2 on 1/29/25, at 9:58 a.m. effective 1/29/25, at 9:56 a.m. stated This nurse went to check on resident before leaving for the night. Resident was alert and verbal. Resident denied any pain or discomfort. The note was entered after the resident's time of death was called at 5:41 a.m.
Review of a late entry progress note entered by LPN, Employee E5 on 1/30/25, at 7:03 a.m. effective 1/29/25, at 6:51 a.m. stated Resident is alert and oriented, denies any pain or discomfort. Resident refused vital signs informed resident vital would be done in the morning. Observed resident three times throughout the night. In the morning found resident absent of all signs. The note was entered after the resident's time of death was called at 5:41 a.m.
During an interview on 2/4/25, at 10:11 a.m. RN, Employee E1 stated if a resident falls, a nurse must complete an assessment, obtain vitals, and document right away in risk management and progress notes. RN, Employee E1 confirmed she failed to ensure documentation was timely entered for Resident R24 after an unwitnessed fall occurred.
During an interview on 2/4/25, at 10:50 a.m. LPN, Employee E2 stated she left the facility around 11:00 p.m. on 1/28/25, and was made aware Resident R24 ceased to breathe on the morning of 1/29/25. LPN, Employee E2 confirmed she failed to ensure documentation was timely entered for Resident R24 after an unwitnessed fall occurred.
During an interview on 2/4/25, at 11:33 a.m. the Nursing Home Administrator confirmed the facility failed to ensure documentation was timely entered for a resident after an unwitnessed fall occurred for one of three residents (Resident R24).
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
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 a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to asse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to assess, document, and notify physicians of an abnormal Capillary Blood Glucose (CBG) levels for one of four residents reviewed (Resident R134), and failed to appropriately respond to a resident's change in condition for one of four residents (Resident R368).
Findings include:
Review of facility policy Obtaining a Fingerstick Glucose Level reviewed 1/15/24, indicated that the procedure is to obtain a blood sample to determine the resident's blood glucose level. The person performing this procedure should record the following information in the resident's medical record:
1. The date and time the procedure was performed.
2. The name and title of the individual(s) who performed the procedure.
3. All assessment data obtained during the procedure.
4. If the resident refused the procedure, the reason(s) why and the intervention taken.
5. The blood sugar result. Follow facility policies and procedures for appropriate nursing interventions regarding blood sugar results (if resident is on sliding scale coverage, and/or physician intervention is needed to adjust insulin or oral mediation dosage), etc.
6. The signature and title of the person recording the data.
The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's. Hyperglycemia, or high blood glucose, occurs when there is too much sugar in the blood. This happens when your body has too little insulin. Hyperglycemia is blood glucose greater than 125 mg/dL while fasting (not eating for at least eight hours, or a blood glucose greater than 180 mg/dL one to two hours after eating. If you have hyperglycemia and it's untreated for long periods of time, you can damage your nerves, blood vessels, tissues, and organs. Damage to blood vessels can increase your risk of heart attack and stroke, and nerve damage may also lead to eye damage, kidney damage and non-healing wounds.
Review of the facility policy Skin Integrity-Skin Tears reviewed 1/15/24, indicated it is the policy of the facility to provide proper treatment and care to maintain skin integrity. Licensed nurses will conduct skin assessments in accordance with facility policy. When a skin tear is discovered, the attending physician will be notified.
Review of the facility policy Change in a Resident's Condition or Status last reviewed 1/15/24, indicated the nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
Review of the clinical record indicated Resident R134 was admitted to the facility on [DATE].
Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/8/25, indicated diagnoses of chronic obstructive pulmonary disease, chronic kidney disease, and diabetes mellitus (metabolic disorder in which the body has high sugar levels for prolonged periods of time).
Review of Resident R134 physician order dated 12/13/24, indicated to administer Humalog KwikPen Subcutaneous Solution Peninjector 100 unit/ml [milliliter] (Insulin Lispro [a short acting, manmade version of human insulin]) Inject as per sliding scale: if 70 - 140 = 0; 141 - 180 = 1; 181 - 220 = 2; 221 - 260 = 3; 261 - 300 = 4; 301 - 340 = 5; 341 - 999 = 6 and call MD, subcutaneously before meals.
Review of Resident R134's care plan dated 1/30/35, indicated Diabetes medication as order by doctor. Monitor/document for side effects and effectiveness. Monitor/document/report as needed any signs or symptoms of hyperglycemia.
Review of Resident R134's eMAR (electronic Medication Administration Record) revealed that the resident's CBG's were as follows:
On 1/28/25, at 8:29 p.m., the CBG was noted to be 500.
Review of Resident R134's eMAR and clinical progress notes indicated the resident was not assessed for hyperglycemia, the blood glucose was not monitored for effectiveness of treatment, staff failed to follow interventions of the care plan, and the physician was not notified of abnormal results on the above listed date.
During an interview on 2/6/25, at 10:00 a.m., the [NAME] President of Clinical Services Employee E9 confirmed that the facility failed to assess, document, and notify physicians of an abnormal Capillary Blood Glucose (CBG) levels for one of four residents reviewed (Resident R134)
Review of the clinical record indicated Resident R368 was admitted to the facility on [DATE].
Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 11/20/24, included diagnoses of high blood pressure, lymphedema (condition that results in swelling of the leg or arm), and an acquired absence of left leg below the knee.
Review of Resident R368's progress note dated 11/29/24, indicated the resident went out for a family visit on Thanksgiving and fell at a family member's house. An open area to the right knee area was observed. Review of the clinical record failed to indicate an assessment of Resident R368's right knee wound or that the doctor was notified.
Review of Resident R368's Nursing-Weekly Skin Evaluation dated 12/5/24, indicated the resident had a left lower leg skin tear. The facility failed to identify the correct anatomical position of the resident's right knee wound and provide a description including measurements.
Review of Resident R368's clinical record revealed a progress note dated 12/11/24, that indicated the resident was seen for follow up and management of the resident's wounds. It was indicated Certified Physician Assistant, Employee E16 spoke with the resident's family member who was concerned about the resident's knee wound from when he fell on Thanksgiving. The resident had a full thickness trauma wound that measured 3 centimeters (cm) x 3 cm x 0.1 cm. It was indicated there was a scant amount of drainage noted and the wound bed was covered with 76-100% slough.
Review of Resident R368's physician order dated 12/12/24, indicated to cleanse the right knee wound with normal saline (solution used to cleanse and irrigate wounds), apply medi honey (wound and burn gel that assists in wound healing and has antibacterial and bacterial resistant properties), and cover with a dry dressing every day shift. The facility failed to obtain a physician order for Resident R368's right knee wound for a total of 14 days.
Review of Resident R368's clinical record on 2/5/25, at 10:18 a.m. failed to include an assessment of Resident R368's right knee wound that included a description and measurement of Resident R368's right knee wound from 11/29/24, through 12/10/24. A total of 13 days.
During an interview on 2/5/25, at 11:26 a.m. the [NAME] President of Clinical Services, Employee E9 confirmed the facility to timely notify a physician, assess and obtain orders for Resident R368's right knee wound.
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 201.29(a) Resident rights.
28 Pa. Code: 201.10(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 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 policies, clinical records, and staff interviews, it was determined that the facility failed to make...
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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 make certain that weight loss was identified and addressed in a timely manner and failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences for one of seven (Resident R121) records reviewed.
Findings include:
Review of facility policy Nutritional Assessment, dated 1/15/24, indicated as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition , shall be conducted for each resident. Individualized care plans shall address, to the extent possible:
a. The identified causes of impaired nutrition;
b. The resident's personal preferences;
c. Goals and benchmarks for improvement;
d. Time frames and parameters for monitoring and reassessment.
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions:
- Section K0300: significant weight loss is defined as 5% weight loss or more in 30 days or 10% weight loss or more in 180 days
GUIDANCE §483.25(g)
Significant weight loss is defined as:
5% or greater in one month
7.5% or greater in three months
10% or greater in six months
Review of the clinical record revealed Resident R121 was originally admitted to the facility on [DATE], with readmission date of 12/31/24.
Review of Resident R121's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/7/25, indicated diagnoses cerebral infarction (also known as an ischemic stroke, occurs when blood flow to the brain is disrupted due to issues with the arteries that supply it), rheumatoid arthritis (chronic inflammatory disorder that affects your joints and other body systems), and, protein-calorie malnutrition.
Review of Resident R121's MDS dated [DATE], Section K - Swallowing/Nutritional Status, Question K0300 Weight Loss was coded 2 indicating a loss of 5% or more in the last month or loss of 10% or more in last 6 months and not on a physician-prescribed weight-loss regimen.
Review of Resident R121's Vitals - Weights revealed the following documented weights:
12/31/2024 - 193.8 lbs (pounds) = 17.5 % weight loss (41.2 lbs) within 1 month
12/6/2024 - 235.0 lbs
12/6/2024 - 230.0 lbs
Review of clinical nutrition/dietary note dated 1/9/25, referenced to coordinate with MDS ARD (Assessment Reference Date) 1/7/25, failed to indicate Resident R121's weight history, and therefore failing to identify and assess resident's significant loss in weight.
Review of Resident R121's nutritional care plan initiated 1/30/25, failed to identify significant weight loss as a nutritional problem, and failed to have updated goals and interventions to monitor, reassess, and address resident's specific nutritional concerns.
During an interview on 2/7/25, at 10:30 a.m., Registered Dietitian (RD) Employee E21 stated that she did not document or address Resident R121's significant weight loss in her clinical notes or care plan, and confirmed that the facility failed to make certain that weight loss was identified and addressed in a timely manner and failed to update an individualized care plan to address the resident's specific nutritional concerns and preferences for one of seven (Resident R121) records reviewed.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interview, it was determined the facility failed to provide appropria...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, clinical record review and staff interview, it was determined the facility failed to provide appropriate care and services to residents receiving tube feedings for two of five residents reviewed (Residents R121, and R269).
Findings Include:
Review of facility policy Enteral Nutrition dated 1/15/24, indicated adequate nutrition support through enteral nutrition is provided to residents as ordered. The Nurse confirms that orders for enteral nutrition are complete. Complete orders include:
- The enteral nutrition product;
- The specific enteral access device (nasogastric, gastric, jejunostomy tube, etc.);
- Administration method (continuous, bolus, intermittent);
- Volume and rate of administration;
- The volume/rate goals
- Instructions for flushing
Review of facility policy Nutritional Assessment, dated 1/15/24, indicated as part of the comprehensive assessment, a nutritional assessment, including current nutritional status and risk factors for impaired nutrition, shall be conducted for each resident. Individualized care plans shall address, to the extent possible:
a. The identified causes of impaired nutrition;
b. The resident's personal preferences;
c. Goals and benchmarks for improvement;
d. Time frames and parameters for monitoring and reassessment.
Review of the clinical record revealed Resident R121 was originally admitted to the facility on [DATE], with readmission date of 12/31/24.
Review of Resident R121's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/7/25, indicated diagnoses cerebral infarction (also known as an ischemic stroke, occurs when blood flow to the brain is disrupted due to issues with the arteries that supply it), rheumatoid arthritis (chronic inflammatory disorder that affects your joints and other body systems), and, protein-calorie malnutrition. MDS Section K0520 indicated a feeding tube present.
Review of physician order dated 12/31/24, indicated an enteral feed order every shift administer [NAME] Farms Standard 1.4 via GT (gastrostomy tube) at a rate of 65cc/hr (cubic centimeter per hour) to begin at 1400 (2:00 p.m.), and end at 0600 (6:00 a.m.). Physician order failed to indicate the total volume of [NAME] Farms 1.4 formula over the 16 hours period of administration, and failed to identify the mechanism for administration (pump or gravity).
Review of Resident R121's current care plan initiated 1/2/25, with revision on 1/30/25, failed to include physician ordered care and services appropriate for receiving enteral nutritional support.
Review of the clinical record revealed Resident R269 was admitted to the facility on [DATE].
Review of Resident R269's clinical record indicated diagnoses on admission to include ischemia of the large intestines (a disorder that develops when blood flow to the colon is partially or completely blocked), high blood pressure, and protein-calorie malnutrition.
Review of Resident R269's clinical progress note on 2/3/25, at 10:59 p.m., indicated resident alert and oriented times 3. PEG tube patent and intact. Tolerating enteral feed, meds, and flushes without difficulty.
Review of physician order dated 1/31/25, indicated an enteral feed order every shift administer Isosource via PEG (Percutaneous endoscopic gastrostomy tube) at a rate of 55ml/hr (milliliters per hour) to begin at 1400 (2:00 p.m.), and end at 0600 (6:00 a.m.). Physician order failed to indicate the total volume of Isosource formula over the 16 hours period of administration, and failed to identify the mechanism for administration (pump or gravity).
During an interview on 2/6/25, at 10:10 a.m., [NAME] President of Clinical Operations Employee E9 confirmed that the facility failed to provide appropriate care and services to residents receiving tube feedings for two of five residents reviewed (Residents R121, and R269).
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.10(c) Resident care policies.
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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen man...
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Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care related to oxygen management for one of four residents (Resident R122).
Findings include:
A review of the facility policy Respiratory Therapy last reviewed on 2/3/25, indicates obtain equipment (i.e., oxygen tubing, reservoir, and distilled water) change the oxygen cannula and tubing every seven days or as needed.
A review of Resident R122's clinical record indicates an admission date of 6/24/22.
A review of R122's Minimum Data Set (MDS-periodic assessment of care needs) dated 12/9/24, indicate the diagnosis of hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD- constriction of airways) and anxiety.
During an observation on 2/3/25, at 10:19 Resident R122 was in bed, her oxygen was on via nasal canula (thin flexible tube used to deliver oxygen). The oxygen tubing failed to be labeled with a date.
During an interview completed on 2/3/25, at 12:03 p.m. Licensed Practical Nurse (LPN) Employee E24 confirmed the oxygen tubing failed to be labeled with a date.
A review of Resident R122's physician orders dated 4/8/24, indicate patient is to remain on 2-5 liters high flow oxygen, patient is 02 (oxygen) dependent every shift and failed to include the percentage of oxygen saturation to maintain comfort or the method of oxygen delivery.
During an interview completed on 2/7/25, at 12:40 p.m. Registered Nurse (RN) Supervisor Employee E13 confirmed the order failed to include the percentage of oxygen saturation to maintain comfort or the method of oxygen delivery and confirmed that the facility failed to provide appropriate respiratory care related to oxygen management for one of four residents (Resident R122).
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(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 F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents receive...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for three of 11 residents reviewed (Resident R23, R45, and R85).
Findings include:
Review of the facility policy Trauma Informed Care dated 2/3/25, indicated the purpose to guide staff in appropriate and compassionate care specific to individuals who have experienced trauma, and post-traumatic stress disorder in the context of the healthcare setting. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident's triggers that are person-centered.
Review of the clinical record indicated Resident R23 was admitted to facility on 8/15/24, with the diagnosis of anxiety, cerebellar ataxia (affects balance gait, and eye movements) and PTSD.
Review of Resident R23's care plan dated 1/19/24, indicated the resident has been exposed to a traumatic event related to PTSD diagnosis. The care plan did not include specific triggers.
There was no documented evidence the facility identified Resident 23's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.
Review of the admission record indicated Resident R45 was admitted to the facility on [DATE].
Review of Resident R45's MDS dated [DATE], indicated the diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture caused by abnormal brain development), high blood pressure, and quadriplegia (a symptom of paralysis that affects all of a person ' s limbs and body from the neck down), and PTSD.
Review of Resident R45's care plan dated 2/5/25, indicated resident has psychosocial well-being problem related to relational trauma by maternal abuse. The care plan did not include specific triggers.
There was no documented evidence the facility identified Resident 45's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.
Review of the clinical record indicated Resident R85 was admitted to facility on 12/3/24.
Review of Resident R85's MDS dated [DATE], indicated the diagnosis of atrial fibrillation (rapid and irregular heart rhythm), bipolar disorder (mental health condition that causes extreme mood swings), and anxiety.
Review of Resident R85's care plan dated 5/5/24, indicated the resident has a psychosocial wellbeing problem actual PTSD related to reported history of physical abuse, vehicular accident.
There was no documented evidence the facility identified Resident 85's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.
Interview with Social Services Director Employee E8, on 2/6/25, at 9:42 a.m. confirmed the facility failed to identify specific triggers, and failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of PTSD for three of 11 residents reviewed (Resident R23, R45, and R85).
28 Pa Code 201.24(e)(4) admission Policy.
28 Pa Code 211.12(a)(d)(3)(5) Nursing Services.
28 Pa. Code 211.16(a) Social 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 clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficul...
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Based on clinical records and facility policy review, and staff interview, it was determined that the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of eleven residents (Resident R23).
Findings include:
Review of the facility policy Trauma Informed Care last reviewed 2/3/25, indicated this facility supports a culture of emotional well-being and physical safety for staff, residents and visitors. Caregivers are taught strategies to help eliminate, mitigate or sensitively address a resident ' s triggers. As part of the comprehensive assessment, identify history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools.
Review of the Social Services job description indicated it is the responsibility of Social Services to ensure that the medically related emotional and social needs of residents are met/maintained on an individual basis. Develop social assessment and care plan, which identifies medically related social and emotional problems and needs with realistic goals and specific actions to be taken.
Review of the clinical record indicated Resident R23 was admitted to facility on 8/15/24, with the diagnosis of bipolar disorder (causes extreme mood swings) post-traumatic stress disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) and anxiety.
Review of the nursing progress notes dated 2/5/25, at 12:18 p.m. physician updated about suicidal ideations which is not new for patient. Social services going to see patient and discuss concerns.
Review of nursing progress note dated 2/5/25, at 4:07 p.m., indicated This writer spoke with social services regarding residents' concerns. Consulted with resident and made aware of how she is feeling and her newly increased anxiety. Placed call to physician informing him of current situation. New orders for Haloperidol 5mg PO (by mouth) q (every) 4 (hours) PRN (as needed) for anxiety. Resident informed and educated on medication purpose and uses. Residence expressed appreciation while tearful but able to verbalize when to seek nursing for guidance and medication as ordered. Will follow up with social services. No other issues at this time. Will continue to monitor.
During an interview on 2/6/25, at 9:42 a.m. Social Services Director Employee E8, indicated if a resident is expressing suicidal ideation, a psychosocial assessment would be completed and confirmed the assessment was not completed for Resdient R23.
Review of Resident R23's care plan on 2/6/25, failed to include interventions for suicidal ideation.
During an interview on 2/6/25, at 12:00 p.m. the Registered Nurse (RN) Supervisor Employee E13 stated I called the physician and received the new orders for Haldol, I had social service talk to her; confirmed the care plan did not have any intervention in place for Resident R23's suicidal ideations and confirmed the facility failed to ensure that a resident who displayed mental or psychosocial adjustment difficulties received appropriate treatment and services for one of eleven residents (Resident R23).
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(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 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 and staff interview, it was determined that the facility failed to develop and implement individ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident 35).
Findings include:
Review of the facility Dementia-Clinical Protocol policy last reviewed 2/3/25, indicated for an individual with a confirmed dementia diagnosis, the interdisciplinary team will identify a resident-care centered care plan to maximize remaining function and quality of life.
Review of Resident R35's clinical record indicated she was admitted to the facility on [DATE], with a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life), anxiety, and depression.
A review of Resident 35's Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 12/22/24, indicated that the facility assessed Resident R635 as having a diagnosis of dementia.
A review of Resident R35's clinical record from 3/9/22, through 2/5/25, failed to indicate that the facility had developed and implemented a person-centered care plan to address the resident's dementia and cognitive loss.
Interview on 2/5/24, at 1:25 p.m. Licensed Practical Nurse, Employee E17 confirmed the facility had no further documentation that the facility developed and implemented individualized person-centered care plans to address Resident R35's dementia diagnosis.
Interview on 2/5/25, at 1:32 the [NAME] President of Clinical Services, Employee E9 confirmed the facility failed to develop and implement individualized person-centered care plans to address dementia and cognitive loss displayed by one of four residents reviewed (Resident 35).
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
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to make...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents receiving psychotropic medications have adequate indication for use for two of five sampled residents (Resident R35 and R43).
Findings include:
Review of the facility policy Psychotropic Medication Use dated 2/3/25, indicated residents will not receive medications that are not clinically indicated.
Review of Resident R35's clinical record indicated she was admitted to the facility on [DATE], with a diagnosis of dementia (loss of memory, language, problem-solving, and other thinking abilities that interfere with daily life), anxiety, and depression.
A review of Resident 35's Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated 12/22/24, indicated that diagnoses were current.
Review of Resident R35's physician order dated 1/26/25, indicated to administer 1.5ml of 2mg/ml Haloperidol Lactate at bedtime for schizophrenia.
Review of Resident R35's physician order dated 1/26/25, indicated to administer 1 ml of 2mg/ml Haloperidol Lactate one time a day for schizophrenia.
Review of Resident R35's clinical record on 2/5/25, at 11:00 a.m. failed to reveal a diagnosis of schizophrenia.
Interview on 2/5/25, at 1:32 the [NAME] President of Clinical Services, Employee E9 confirmed the facility failed to ensure Resident R35's medication regime was free from potentially unnecessary medications.
Review of the admission record indicated R43 was admitted to the facility on [DATE].
Review of Resident R43's MDS dated [DATE], indicated the diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness), and anemia.
Review of Resident R43's physician order dated 10/25/24, indicated Risperdal (an anti-psychotic medication) give 0.5 mg (milligrams) two times a day for depression.
Review of Resident R43's Medication Administration Record (MAR) dated February 2025, indicated resident was receiving the medication as prescribed.
Interview on 2/5/25, at 2:38 p.m. Registered Nurse (RN) Supervisor Employee E13 confirmed the facility failed to have an appropriate indication for use diagnosis in the physician order for the antipsychotic medication Risperdal.
Interview on 2/6/25, at 3:00 p.m. the Director of Nursing confirmed the facility failed to make certain that residents receiving psychotropic medications have adequate indication for two of five sampled residents (Resident R35 and R43).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(a)(b)(3) Management.
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 F0761
(Tag F0761)
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 properly store medical supplies and biologicals in one of five medication carts (5th ...
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Based on review of facility policy, observations and staff interview it was determined that the facility failed to properly store medical supplies and biologicals in one of five medication carts (5th floor front hall medication cart) and one of three medication rooms (6th floor medication room).
Findings include:
A review of the facility policy Medication Labeling and Storage last reviewed 2/3/25, indicates medications for external use, as well as hazardous drugs and biologicals, are clearly marked as such, and are stored separately from other medications.
A review of the facility policy Administering Medications last reviewed 2/3/25, indicated the expiration/beyond use date on the medication label must be checked prior to administering. When opening a multi dose container, the date opened shall be recorded on the container.
During an observation on 2/3/25, at 12:12 p.m. the 5th floor front hall medication cart contained the following:
. A bottle of Tums antacid tablets not labeled with date opened.
. A small white bottle of shaving cream.
. A can of sweet vanilla rainbow room spray.
During an interview completed on 2/3/25 at 12:17 p.m. Licensed Practical Nurse (LPN) Employee E6 confirmed the above observations.
During an observation of the 6th floor medication storage room the following was discovered stored under the sink:
. 7 packages of briefs.
. One bottle of drug disposal liquid.
During an interview on 2/4/25, at 10:48 a.m. Registered Nurse (RN) Employee E1 confirmed the above observation and that the facility failed to properly store medical supplies and biologicals in one of five medication carts (5th floor front hall medication cart) and one of three medication rooms (6th floor medication room).
28 Pa. Code:211.12(d)(1)(2)(3)(5) Nursing services.
28 Pa. Code: 211.9(a)(1)(h)(k)(l)(1) Pharmacy services.
28 Pa. Code: 211.10(c) 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
Antibiotic Stewardship
(Tag F0881)
Could have caused harm · This affected 1 resident
Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for four of t...
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Based on review of the facility's infection control policies and procedures and staff interview, it was determined that the facility failed to implement an antibiotic stewardship program for four of ten months (April 2024, May 2024, June 2024, July 2024).
Findings include:
Review of facility policy Infection Control Program reviewed 1/15/24, indicated antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The purpose of the facility's Antibiotic Stewardship Program is to monitor the use of antibiotics in the residents.
Review of facility policy Surveillance for Infections, last reviewed 1/15/24, indicated The Infection Preventionist will conduct ongoing surveillance for Healthcare-Associated Infections (HAIs) and other epidemiologically significant infections that have substantial impact on potential resident outcome and that may require transmission-based precautions and other preventative interventions. The Infection Preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data.
Review of the facility's Infection Control surveillance for April 2024 - January 2025, failed to include documentation to indicate that antibiotic monitoring was completed for four of ten months (April through July 2024).
During an interview on 2/5/24, at 2:45 p.m., the [NAME] President of Clinical Services confirmed that the facility failed to implement an antibiotic stewardship program that included a system of surveillance to monitor antibiotic use and lab correlation for infections for four of ten months and was unable to produce the tracking records for April 2024, May 2024, June 2024, and July 2024.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, it was determined that the facility failed to maintain an effective call system for 12 of 20 resident restrooms on one of five floors (6th floor).
Findings i...
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Based on observation and staff interview, it was determined that the facility failed to maintain an effective call system for 12 of 20 resident restrooms on one of five floors (6th floor).
Findings include:
Review of facility policy Call System, Resident last reviewed 2/3/25, indicates residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized work station
During a group interview on 2/4/25, at 10:15 a.m. Residents indicated that the call bell in the bathroom did not work and it didn't let staff know that they needed help.
During an observation on 2/5/25, 10:30 am thru 11:08 a.m. of the sixth-floor resident restrooms the following rooms were observed to have call light cords that when pulled were unable to be alarmed:
. 6010
. 6011
. 6012
. 6013
. 6016
. 6017
. 6018
. 6019
. 6020
. 6021
. 6023
. 6040
During an interview completed on 2/4/25, at 11:10 a.m. Nurse Aid (NA) Employee E26 confirmed the above observations.
During an interview completed on 2/4/25, at 11:34 a.m. the Nursing Home Administrator confirmed that the facility failed to maintain an effective call system for 12 of 20 resident restrooms on one of five floors (6th floor).
28 Pa Code 201.14 (a) Responsibility of licensee.
28 Pa Code 201.18 (b)(1) Management.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation and interviews with staff, it was determined that the facility failed to develop, impl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility documentation and interviews with staff, it was determined that the facility failed to develop, implement, and maintain an effective training program that was sufficient to meet the requirement for facility-provided annual nurse aide education for three of five employee files (Nurse Aide (NA) Employees E3, E14, and E15).
Findings include:
Review of NA Employee E3's personnel record indicated she was hired to the facility on 9/9/20.
Review of NA Employee E14's personnel record indicated she was hired to the facility on [DATE].
Review of NA Employee E15's personnel record indicated she was hired to the facility on 8/19/20.
Review of annual in-service documentation and personnel records did not include an annual in-service training on Quality Assurance and Performance Improvement (QAPI), Communication, and Compliance and Ethics training.
Interview on 2/5/25, at 1:54 p.m. the Director of Nursing confirmed that facility failed to develop, implement, and maintain an effective training program that was sufficient to meet the requirement for facility-provided annual nurse aide education for three of five employee files (Nurse Aide (NA) Employees E3, E14, and E15).
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.20 (a) (c) Staff development
28 Pa. Code 201.29 (d) Resident rights
28 Pa. Code 201.19(7) Personnel policies and procedures.
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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on policy, resident and staff interview interviews, and observations it was determined that the facility failed to make certain the grievance policy was posted prominently throughout the facilit...
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Based on policy, resident and staff interview interviews, and observations it was determined that the facility failed to make certain the grievance policy was posted prominently throughout the facility, failed to include an anonymous place and the address, email and phone number for the grievance officer for 5 of 5 nursing units.
Findings include:
§483.10(j) Grievances.
§483.10(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance.
Review of facility policy Filing Grievances/Complaints dated 2/3/25, indicated Our facility will help residents, their representatives (sponsors), other interested family members, or resident advocates file grievances or complaints when such requests are made.
Resident group on 2/4/25, at 10:30 a.m. indicated they were unaware of the grievance policy and procedure and how to file anonymously.
During observations on 2/6/25, from 1:05 p.m. to 1:38 p.m. on second floor nursing unit to sixth floor nursing unit failed to include the grievance policy posted throughout the facility, failed to include how and where an anonymous place to file grievances were located. The posting for grievance failed to include the business address, email, and phone number.
During an interview on 2/7/25, at 11:44 a.m. Director of Social Services Employee E8 confirmed that the facility failed to make certain that the grievance policy was posted prominently throughout the facility failed to include an anonymous place for grievances, failed to include all the required information to include address, email and phone number for grievance officer.
28 Pa. Code 201.29(1)Resident rights.
28 P. Code 201.18 (e )(4)Management.
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
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to make certain that the ne...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interviews, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of six residents sampled with facility-initiated transfers (Residents R80, R105 and R124).
Findings include:
Review of the facility policy Transfer or Discharge, Facility-Initiated reviewed 1/15/24, and again on 2/3/25, indicated information conveyed to receiving provider, and documentation of transfer to include the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
Review of the clinical record indicated Resident R80 was admitted to the facility on [DATE].
Review of Resident R80's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/13/25, indicated diagnosis of hypertension (high blood pressure), hyperlipidemia (high fat in the blood) and aphasia (loss of ability to understand or express speech).
Review of Resident R80's clinical record revealed that the resident was transferred to the hospital on 1/3/25.
Review of Resident R80's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the resident ' s transfer, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
Review of the clinical record indicated Resident R105 was admitted to the facility on [DATE].
Review of Resident R105's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/9/25, indicated diagnoses of anxiety (intense, excessive, and persistent worry and fear about everyday situations), bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and depression.
Review of Resident R105's clinical record revealed that the resident was transferred to the hospital on 1/29/25.
Review of Resident R105's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transfer, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
Review of the clinical record indicated Resident R124 was admitted to the facility on [DATE].
Review of Resident R124's MDS dated [DATE], indicated diagnoses of high blood pressure, stroke (damage to the brain from an interruption of blood supply), and hemiplegia (paralysis of one side of the body).
Review of Resident 124's clinical record revealed that the resident was transferred to the hospital on 9/27/24.
Review of Resident R124's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transfer, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.
Interview on 2/7/25, at 9:33 a.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of six residents sampled with facility-initiated transfers (Residents R80, R105 and R124).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(a)(b)(3) Management.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
28 Pa. Code: 211.12 (d)(1)(3)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interviews it was determined that the facility failed to make cer...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records and staff interviews it was determined that the facility failed to make certain that resident assessments were accurate for four of 12 residents (Residents R51, R90, R117, and R164).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated that Section C: Cognitive Patterns, Question C0100 Should Brief Interview for Mental Status Be Conducted? (BIMS) should be coded as 0 if the resident is rarely/never understood, and that it should be coded 1, and the BIMS assessment should be completed if the resident is at least sometimes understood.
Further review of the RAI indicated under Coding Tips rules for stopping the BIMS before it is complete:
1. All responses up to this point have been nonsensical (making no sense),
2. there has been no verbal or written response to any of the questions up to this point, or
3. there has been no verbal or written response to some questions up to this point
and for all others, the resident has given a nonsensical response.
The remaining questions would be filled out with a dash (-).
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (periodic assessments of resident care needs), dated October 2024, indicated that Section K: Swallowing/Nutrition Status, Question K0300, Weight loss, Code 1, yes on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was planned and pursuant to a physician's order. In cases where a resident has a weight loss of 5% or more in 30 days or 10% or more in 180 days as a result of any physician ordered diet plan or expected weight loss due to loss of fluid with physician orders for diuretics, K0300 can be coded as 1.
Review of the admission record indicated Resident R51 was admitted to the facility on [DATE].
Review of Resident R51's MDS dated [DATE], indicated the diagnoses of anxiety ( repeated episodes of sudden feelings of intense anxiety and fear or terror), schizophrenia ( is a mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness and social interactions), and depression (mood disorder that causes persistent feelings of sadness and loss of interest). Section C- Cognitive Patterns, Question C0100 indicated that Resident R51 should receive a BIMS interview. Section C had dashes entered for the remainder of the interview questions.
Interview on 2/6/25, at 9:06 a.m. Director of Social Services Employee E8 confirmed that the facility failed to certain that Resident R51 MDS assessment was accurate.
Review of the admission record indicated Resident R90 was admitted to the facility on [DATE].
Review of Resident R90's MDS dated [DATE], indicated the diagnoses of high blood pressure, arthritis, and osteoporosis (a condition in which bones become weak and brittle). Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R90 understands and can be understood. Section C: Cognitive Patterns, Question C0100 indicated that Resident R90 should receive a BIMS interview. Section C had dashes entered for the remainder of the interview questions.
Review of the admission record indicated Resident R117 was admitted to the facility on [DATE].
Review of Resident R117's MDS dated [DATE], indicated the diagnosis of hypertension (high blood pressure), diabetes (high sugar in the blood) and hyperlipidemia (high fat in the blood). Section B: Hearing, Speech, and Vision, Question B0700 indicated that Resident R117 usually understood and usually understands. Section C: Cognitive Patterns, Question C0100 indicated that Resident R117 should receive a BIMS interview. Section C had dashes entered for the remainder of the interview questions.
Interview on 02/06/25, at 8:54 a.m. with Director of Social Services Employee E8 indicated I do not assess, as an example, when they are sleeping. I don't fill it in. Should I be doing it another way?
Review of admission record indicated that Resident R164 was admitted to the facility 12/27/24.
Review of Resident R164's MDS dated [DATE], indicated the diagnoses necrotizing fasciitis (serious bacterial infection that results in the death of the body's soft tissue), high blood pressure, and protein-calorie malnutrition. Section K, Question 0200, Height and Weight, indicate that a Height of 72 inches, and weight of 133 pounds; Question K0300, Weight loss, was coded 1. Yes, on physician-prescribed weight-loss regimen.
Review of clinical record indicated that Resident R164 weight as documented on 12/28/24, was 132.8 pounds. No additional weights were available for comparison based on criteria from RAI manual.
Review of clinical physician progress notes failed to indicate documentation that Resident R164 was on a physician-prescribed weight-loss regimen.
Review of clinical nutrition progress notes failed to indicate documentation that Resident R164 was on a physician-prescribed weight-loss regimen.
During an interview on 2/5/25, at 1:50 p.m., Registered Dietitian (RD) Employee E21 revealed that Resident R164 did not have significant weight loss and was not on a physician-prescribed weight-lose regimen. RD Employee E21 revealed that MDS information was entered in error.
During an interview on 2/5/25, at 3:00 p.m., Registered Nurse Assessment Coordinator (RNAC) Employee E22 confirmed that Section K, Question 0300, Weight loss was entered in error.
Interview on 2/6/25, at 3:00 p.m. the [NAME] President of Clinical Services Employee E9 confirmed the facility failed to make certain that resident assessments were accurate for four of 12 residents (Residents R64, R90, R117, and R164).
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observation, clinical record review, 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 facility policy, observation, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to prevent further decrease in range of motion for five of seven residents (Residents R15, R22, R43, R45, and R50).
Findings include:
Review of the facility policy Assistive Devices and Equipment dated 2/3/25, indicated the facility maintains and supervised the use of assistive devices and equipment for residents. Staff are trained and demonstrate competency on the use of devices and equipment prior to assisting or supervising residents.
Review of the admission record indicated R15 was admitted to the facility on [DATE].
Review of Resident R15's Minimum Data Set (MDS - a periodic assessment of care needs) dated 5/31/24, indicated the diagnoses of stroke (damage to the brain from an interruption of blood supply), anemia (the blood doesn't have enough healthy red blood cells), and atrial fibrillation (irregular heart rhythm).
Review of Resident R15's physician order dated 12/20/24, indicated wear left palm guard (splint that positions the fingers away from the palm to protect the skin from moisture, pressure, and nail puncture) with finger separators three to four hours daily during daylight shift as tolerated by the resident. Remove for care and check skin integrity before and after putting on and taking off palm guard.
Review of Resident R15's care plan dated 2/3/25, indicated wear left palm guard with finger separators three to four hours daily during daylight shift as tolerated by the resident. Remove for care and check skin integrity before and after putting on and taking off palm guard.
Observations on 2/3/25, at 9:00 a.m., 2/4/25, at 9:15 a.m., and 2/5/25, at 11:12 a.m., Resident R15 was observed in room with left hand contracture (an abnormal thickening of tissues in the palm of the hand that over time can cause the fingers to curl in toward the palm) without the palm guard in place as ordered.
Interview on 2/5/25, at 11:12 a.m. Licensed Practical Nurse (LPN) Employee E10 confirmed Resident R15's left hand was contracted and that the brace was not present over the past three days.
Review of the admission record indicated R22 was admitted to the facility on [DATE].
Review of Resident R22's MDS dated [DATE], indicated the diagnoses of Non-Alzheimer's Dementia (dementia caused by other diseases with symptoms forgetfulness, limited social skills, and impaired thinking abilities that interfere with daily functioning), Bipolar (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), and high blood pressure.
Review of Resident R22's physician order dated 5/11/23, indicated resident is to use bilateral (both sides) wedges at lateral sides of knees and bilateral heel lift boots at all times when in bed except for during care.
Review of Resident R22's physician order dated 10/4/23, indicated resident to use left knee extension splint (for gradual extension of nonfixed knee contracture) three to four hours daily during daylight shift, may remove for care.
Review of Resident R22's care plan dated 2/3/25, indicated resident is to use bilateral wedges at lateral sides of knees and bilateral heel lift boots at all times when in bed except for during care, and resident to use left knee extension splint three to four hours daily during daylight shift, may remove for care.
Observations on 2/3/25, at 9:00 a.m., 2/4/25, at 9:15 a.m., and 2/5/25, at 11:12 a.m., Resident R22 was observed in bed, without bilateral wedges at lateral sides of knees and bilateral heel lift boots, and without left knee extension splint. Equipment noted on the top of the wardrobe closet.
Interview on 2/5/25, at 11:15 a.m. Nurse Aide (NA) Employee E11 indicated there is only one restorative staff for the entire facility with five separate floors, and restorative isn't here every day, and frequently gets pulled to care assignments. The floor aides do not apply the splints. I know he hasn't had them on for the last three days.
Review of the admission record indicated R43 was admitted to the facility on [DATE].
Review of Resident R43's MDS dated [DATE], indicated the diagnoses of schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), seizure disorder (a person experiences abnormal behaviors, symptoms and sensations, sometimes including loss of consciousness), and anemia.
Review of Resident R43's care plan dated 1/23/25, indicated resident is dependent for all activities of daily living and care needs.
Observations on 2/4/25, at 9:15 a.m., and 2/5/25, at 11:12 a.m., Resident R22 was observed in bed, with left hand visibly contracted.
Interview on 2/5/25, at 11:20 a.m. LPN Employee E10 confirmed Resident R22 had a left-hand contracture and that he did not have a splint ordered as required to protect his palm.
Review of the admission record indicated R45 was admitted to the facility on [DATE].
Review of Resident R45's MDS dated [DATE], indicated the diagnoses of cerebral palsy (a congenital disorder of movement, muscle tone, or posture caused by abnormal brain development), high blood pressure, and quadriplegia (a symptom of paralysis that affects all of a person's limbs and body from the neck down).
Review of Resident R45's current physician orders indicated resident to wear right elbow extension splint and left-hand splint at the same time for two to four hours during the daylight shift alternating with left elbow and right-hand splints for two to four hours during the daylight shift as tolerated by resident. Off during meals.
Review of Resident R45's care plan dated 11/19/24, indicated resident to wear right elbow extension splint and left-hand splint at the same time for two to four hours during the daylight shift alternating with left elbow and right-hand splints for two to four hours during the daylight shift as tolerated by resident. Off during meals.
Observations on 2/3/25, at 9:00 a.m., and 2/5/25, at 11:12 a.m., Resident R45 was observed in bed, without his right elbow extension splint and left-hand splint, or his left elbow and right-hand splints.
Interview on 2/5/25, at 11:30 a.m. Nurse Aide (NA) Employee E11 confirmed Resident R45 has not been wearing his splints as ordered, and the floor aides do not apply the assistive devices.
Review of the admission record indicated R50 was admitted to the facility on [DATE], and readmitted [DATE].
Review of Resident R50's MDS dated [DATE], indicated the diagnoses of acquired absence of right leg below knee, contracture, and muscle weakness.
Review of Resident R50's current physician orders dated 12/4/24, indicated resident to wear left knee extension splint when in bed for 3-4 hours during the daylight shift as tolerated by resident.
Review of Resident R50's care plan dated 2/3/25, indicated resident to wear left knee extension splint when in bed 3-4 hours daily during the daylight shift as tolerated by the resident. The facility failed to timely implement a care plan for Resident R50's splint. A total of 61 days since the resident was ordered the left knee extension splint.
During an observation and interview on 2/3/25, at 9:55 a.m., Resident R50 was observed in bed without his left knee extension splint. Resident R50 indicated the facility does nothing for his good leg.
During an observation and interview on 2/3/25, at 12:49 p.m. Resident R50 was observed again without his left knee extension splint. He indicated he is supposed to have an arm brace too. Resident R50 stated he only had his knee brace on about one to two times since he's been in the facility. Resident R50 indicated no one has offered him his left knee extension splint and stated he is unsure where it even is.
During an interview on 2/3/25, at 12:56 p.m. Licensed Practical Nurse, Employee E17 was asked if he seen Resident R50's left knee extension splint and he stated I don't know if I seen it the last few days, honestly I haven't looked. LPN, Employee E17 confirmed the facility failed to provide Resident R50's left knee extension splint as ordered.
During an observation on 2/5/25, at 11:42 a.m. Resident R50 was observed lying in bed without his left knee extension splint intact. He indicated he is unsure if he has one.
During an interview on 2/5/25, at 11:51 a.m. LPN, Employee E19 confirmed Resident R50's knee splint was not available and she was unsure where it was.
Interview on 2/5/25, at 11:50 a.m. [NAME] President of Clinical Employee E9 indicated the restorative program is broken and confirmed the facility failed to provide treatment and services to prevent further decrease in range of motion for five of seven residents (Residents R15, R22, R43, R45, and R50).
28 Pa. Code: 201.29(j) Resident rights.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical records, observation, and staff interviews, it was determined that the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, resident clinical records, observation, and staff interviews, it was determined that the facility failed to report, implement infection monitoring and management for COVID-19, and test residents timely for respiratory illnesses for two of two residents (Resident R80 and R369) and failed to prevent cross contamination during a medication pass for one of two residents (Resident R37).
Finding include:
Review of the facility Outbreak of Communicable Diseases reviewed 1/15/24, indicated outbreaks of communicable diseases within the facility are promptly identified and managed. An outbreak is defined as one case of an infection that is highly communicable or has serious implications. The administrator is responsible for communicating data about reportable diseases to the health department. The infection preventionist and director of nursing are responsible for managing surveillance data, monitoring ill residents and staff.
Review of the Bureau of Epidemiology Respiratory Virus Outbreak Toolkit last updated 11/14/24, indicated long term care facilities need to procure their own testing supplies and the lab support needed to detect respiratory viruses like COVID-19, Influenza, and RSV in both residents and Health Care Personnel. If the respiratory virus is not one of the three for which there are point0of0care tests available, a lab needs to be available to perform an expanded respiratory panel. One laboratory-confirmed COVID-19 case indicates an outbreak. All respiratory outbreaks are reportable and must be reported to Department of Health within 24 hours of identification of the outbreak. When respiratory illness is first identified in residents or staff ,the facility should implement daily symptoms monitoring and testing. A case line listing is designed to collect information about ill cases for residents and staff during an outbreak and can track the spread of the virus and monitor case counts until the outbreak has finished. An outbreak is considered over: when 14 days have passed since he last resident tested positive or became symptomatic (if no positive test). Any new infections in a resident for the applicable virus would restart the 14-daycountdown.
Review of the facility policy Administering Medications last reviewed 2/3/25, indicates staff shall follow established facility infection control procedures (e.g., handwashing, antiseptic techniques, gloves, isolation precaution, etc.) for the administration of medications, as applicable.
Review of the clinical record indicated Resident R369 was admitted to the facility on [DATE].
Review of Resident R369's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/17/24, indicated diagnoses of opioid dependence, respiratory conditions due to smoke inhalation, and hip fracture.
Review of Resident R369's progress note dated 12/19/25, indicated the resident complained of shortness of breath while sitting and walking. Resident R369 was not tested for respiratory illnesses.
Review of Resident R369's progress note dated 12/20/24, at 9:14 a.m. indicated the resident had increased anxiety and a moist productive cough. Resident had left lower scattered rhonchi. It was indicated the resident was self-expectorating white phlegm. Resident R369 was not tested for respiratory illnesses.
Review of Resident R369's progress note dated 12/23/24, indicated the resident was waiting to go to an appointment in the lobby and complained of shortness of breath and his heart racing. The resident was sent to hospital for further evaluation.
Review of Resident R369's progress note dated 12/24/24, entered by Infection Preventionist, Employee E20 indicated the resident tested positive for COVID. Will retest in 5 days per CDC recommendations.
Review of documentation provided to the local state field office from 12/23/24, to 2/4/25, failed to include Resident R369's positive COVID diagnosis.
Review of the clinical record indicated Resident R80 was admitted to the facility on [DATE].
Review of Resident R80's MDS dated [DATE], indicated diagnoses of anxiety, depression, and muscle weakness.
Review of Resident R80's progress note dated 1/1/25, indicated the resident has a cough and congestion. It was indicated the resident had audible wheezing noted on both inspiration and expiration. Resident R80 was not tested for respiratory illnesses during the facility's COVID outbreak.
Review of Resident R80's progress note dated 1/3/25, indicated Registered Nurse, Employee E19 was called to assess the resident. It was indicated the resident was short of breathe and rhonchi (abnormal loud, continuous, low-pitched, snoring, or gurgling lung sound) was noted in the upper lungs. The resident's oxygen saturation (refer to the amount of oxygen circulating in the blood) was 84% on room air and 3 liters (L) of oxygen was applied via nasal cannula and the residents oxygen saturation improved to 90%. The resident's doctor and family was notified and the resident was transferred to the hospital. The resident was admitted with cough.
During an interview on 2/5/25,at 10:21 a.m. Infection Preventionist, Employee E20 stated the facility in not currently in outbreak for COVID. The last outbreak was when Resident R369 tested positive for COVID was on 12/24/24. IP, Employee E20 indicated the facility completed a unit-based approach for outbreak testing. IP, Employee E20 stated she tested residents the day she received notification Resident R369 tested positive and on Day 5. IP, Employee failed to test residents on Day 3, as required. IP, Employee E20 stated the facility monitored residents after Day 5 and tested residents if they developed symptoms. IP, Employee E20 confirmed the facility failed to develop a line listing report for the facility's COVID outbreak that began on 12/24/24.
During an interview on 2/6/25, at 9:16 a.m. the [NAME] President of Clinical Services, Employee E9 confirmed the facility failed to report, implement infection monitoring and management for COVID-19, and test residents timely for respiratory illnesses for two of two residents (Resident R80 and R369).
During a medication pass observation completed on 2/4/25, at 9:00 a.m. Licensed Practical Nurse (LPN) Employee E23 administered Resident R152's medications, exited the room, removed gloves, donned a new pair of gloves, and began to prepare Resident R37's medications without completing hand hygiene.
During an interview completed on 2/4/25, at 9:12 a.m. LPN Employee E23 confirmed administration of Resident R152's medication, exiting the room, removing gloves and donning a new pair of gloves without completing hand hygiene prior to beginning the preparation of R37's medications and that the facility failed to prevent cross contamination during a medication pass for one of two residents (Resident R37).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
28 Pa. Code: 211.12(d)(3) Nursing services.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross...
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Based on a review of policy, observation and staff interview, it was determined that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.
Findings include:
Review of facility policy Food Safety Requirements: Sanitation of the Kitchen dated 2/3/25, indicated that Food Service Staff maintain the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule.
During an observation of the main designated kitchen on 2/3/25, initiated at 9:30 a.m., with Dietary Director Employee E25, the following was observed:
- Walk-in cooler #3, at 9:45 a.m.;
-- the cold air condenser fan covers had a build-up of dust, grime, and dark colored debris.
-- the floor had a build-up of grime and dried food debris below stored cases of milk.
- Walk-in cooler #4, at 9:50 a.m.;
-- the cold air condenser fan covers had a build-up of dust, grime, and dark colored debris; areas around the cooler fans immediately adjacent to and on ceiling forward of the fans had a build-up of dust, grime, and dark colored debris.
Above observations were confirmed by Dietary Director Employee E25 at time viewed with surveyor.
During an interview on 2/3/25, at 9:52 a.m., Dietary Director Employee E25 confirmed that the facility failed to properly maintain kitchen equipment in a sanitary condition creating the potential for cross contamination in the main kitchen of the facility.
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Deficiency F0570
(Tag F0570)
Minor procedural issue · This affected most or all residents
Based on review of facility documentation and staff interviews it was determined that the facility failed to ensure that the surety bond had sufficient funds to cover the residents personal funds for ...
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Based on review of facility documentation and staff interviews it was determined that the facility failed to ensure that the surety bond had sufficient funds to cover the residents personal funds for three of three months (November 2024, December 2024, and January 2025).
Findings include:
Review of facility bank statements indicated:
November 2024 - $409,305.82
December 2024 - $406,090.88
January 2025 - $405,479.42
Review of facility surety bond indicates the amount covered equaled$300,000.
During an interview on 2/6/25, at 11:31 a.m. Regional Business Office Manger confirmed that the facility failed to ensure that the surety bond covered the resident trust fund for November 2024, December 2024 and January 2025.
28 Pa.Code 201.14(a)Responsibility of licensee.
28 Pa. Code 201.18(b)(2)Management.
Jul 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0620
(Tag F0620)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident records, admission documentation and staff interview, it was determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident records, admission documentation and staff interview, it was determined that the facility failed to maintain admission documentation for two of seven residents (Resident R1, R7).
Findings include:
Review of Resident R1 was admitted [DATE] with diagnoses that include dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia and COPD (COPD, or chronic obstructive pulmonary disease, is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe).
Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2019, indicated that a Brief Interview for Mental Status (BIMS) is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment
Review of Resident R1 admission MDS assessment ( Minimum Data Set assessment MDS- a periodic assessment of resident care needs) dated 6/25/24 indicated the resident was assessed as having a BIMS score of 10, which indicates moderately impaired.
Review of Resident R1's admission packet dated 6/20/24 indicated a signature from R1.
Review of Resident R6 was admitted [DATE] with diagnoses that include catatonic disorder (group of symptoms that usually involve a lack of movement and communication, and also can include agitation, confusion) and schizophrenia.
Review of Resident R6's admission packet dated 3/12/24 indicated a no signature from resident or POA (power of Attorney).
During an interview with Nursing Home Administrator on 7/26/24 at 11:30 a.m. confirmed Resident R1 was cognitivly impaired and should not have signed facility paperwork and R6 never had his admission paper work completed as required.
28 Pa Code: 201.18(b)(2) Management
28 Pa Code: 201.24(a) admission policy
28 Pa Code: 201.19(i) Residents rights
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for four of seven residents reviewed (Residen...
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Based on clinical record review and staff interview, it was determined that the facility failed to ensure that clinical records were complete and accurate for four of seven residents reviewed (Residents R1, R2, R3 and R4).
Review of Resident R1's admission record indicated the resident was admitted to the facility 6/18/24, with the diagnoses of dementia(a general term for loss of memory, language, problem solving that are severe enough to interfere with daily life), anemia and COPD (chronic obstructive pulmonary disease, is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe).
Review of Resident R1's EMR (electronic medical record) and paper file indicated no Inventory Sheet( form used to log resident belongings on admission).
Review of Resident R2's admission record indicated the resident was admitted to the facility 7/1/24, with diagnoses of bipolar disorder, end stage renal disease and renal dialysis dependence.
Review of Resident R2's EMR (electronic medical record) and paper file indicated no Inventory Sheet( form used to log resident belongings on admission).
Review of Resident R3's admission record indicated the resident was admitted to the facility 7/27/20, with the diagnoses of dementia (a general term for loss of memory, language, problem solving that are severe enough to interfere with daily life), depression and schizoaffective disorder.
Review of Resident R3's EMR (electronic medical record) and paper file indicated no Inventory Sheet( form used to log resident belongings on admission).
Review of Resident R4's admission record indicated the resident was admitted to the facility 10/27/23, with diagnoses of dementia (a general term for loss of memory, language, problem solving that are severe enough to interfere with daily life) and malignant neoplasm of the lung.
Review of Resident R4's EMR (electronic medical record) and paper file indicated no Inventory Sheet( form used to log resident belongings on admission).
During an interview on 7/25/24, at 11:30 a.m. the Nursing Home Administrator confirmed the Resident R1, R2, R3 and R4 medical records were incomplete and not accurate for four of seven reviewed.
28 Pa. Code 111.5(f) Clinical records
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on pest control service logs, observations, and staff interview it was determined that the facility failed to maintain an ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on pest control service logs, observations, and staff interview it was determined that the facility failed to maintain an effective pest control program for one out of two nurses stations (2nd floor) and two out of three rooms (2nd floor).
Findings include:
Review of records of invoices from pest control provider dated May-July 2024 , indicated that mouse traps were laid out; however, the record did not include evidence of efforts to eradicate mice on the 2nd floor nursing unit in July 2024.
During observation on 7/25/24, the 2nd floor was observed with the following:
At 10 a.m. observations of three glue traps beside the unit refrigerator.
rooms [ROOM NUMBERS] glue traps in rooms under the heating units.
During an interview on 7/25/24 at 10:30 a.m. Resident R5 indicated he has seen mice and cockroaches on the nursing unit. Review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 6/27/24, indicated Resident R5 has a BIMS (Interview for Mental Status), cognitively intact.
During an interview on 7/25/24 at 1:30 p.m. Nursing Home Administrator confirmed the facily failed to maintain an effective pest control program as required.
28 Pa. Code.18(e)(2) Management
28 Pa. Code 207.20(a) Administrator's responsibility
Mar 2024
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to accommodate ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation, and staff interview, it was determined that the facility failed to accommodate the call bell needs of four of four residents (Resident R5, R18, R75, and R86).
Findings include:
Review of facility policy Answering the Call Light dated 1/15 /24, indicated all residents who are in bed or confined to a chair be sure the call light is within easy reach of the resident.
Review of the clinical record indicated Resident R5 was admitted to the facility on [DATE].
Review of Resident R5's Minimum Data Set (MDS - a periodic assessment of care needs) dated 1/11/24, indicated diagnoses of hypertension (high blood pressure), heart failure (a progressive heart disease that affects pumping action of the heart muscles) and, Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior).
During an observation on 3/18/24, at 10:04 a.m. Resident R5 was observed lying in bed with his call light placed behind his dresser, completely out of the resident's reach.
Review of the clinical record indicated Resident R18 was admitted to the facility on [DATE].
Review of Resident R18's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/15/24, indicated diagnoses of dementia (a group of symptoms that affects memory, thinking and interferes with daily life), hypertension and anxiety.
During an observation on 3/18/24, at 9:36 a.m. Resident R18 was observed lying in bed with his call light twisted up in a ball and hanging from the wall, completely out of the resident's reach.
Review of the clinical record indicated Resident 75 was admitted to the facility on [DATE].
Review of Resident R75's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/27/24, indicated diagnoses of stroke (damage to the brain from interruption of its blood supply), hypertension and, depression (a group of conditions associated with the elevation or lowering of a person's mood).
During an observation on 3/18/24, at 9:26 a.m. Resident R75 was observed sitting in his wheelchair beside his bed with his call bell on the floor, completely out of the resident's reach.
Review of the clinical record indicated Resident 86 was admitted to the facility on [DATE].
Review of Resident R86's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/28/24, indicated diagnoses of stroke (damage to the brain from interruption of its blood supply), hypertension and, depression (a group of conditions associated with the elevation or lowering of a person's mood).
During an observation on 3/18/24, at 9:40 a.m. Resident 86 was observed lying in his bed with his call bell on the floor, completely out of the resident's reach.
During an interview on 3/18/24, at 10:09 a.m. Licensed Practical Nurse (LPN) Employee E1 confirmed Resident R5, R18, R75 and R86's call bells where not accessible and unavailable for use to the resident.
During an interview on 3/22/24, at 9:56 a.m. the Director of Nursing confirmed that the facility failed to accommodate the call bell needs of four of four residents (Resident R5, R18, R75, and R86).
28 Pa. Code: 201.29(j) Resident rights.
28 Pa. Code: 211.10(d) 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
Investigate Abuse
(Tag F0610)
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 staff interviews, 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 policies, clinical record reviews and staff interviews, it was determined that the facility failed to initiate a thorough investigation that included statements from the witnesses and/or statements from the residents for injuries of unknown origin for one of six residents (Residents R38).
Findings include:
The facility Incidents and Accidents-Investigating and Reporting policy dated 1/15/24, indicated the charge nurse or nurse supervisor and/or department director or supervisor shall promptly initiate and document investigation of the accident or incident. The name of witnesses and their accounts of the incident must be included.
The facility Abuse Investigation and Reporting policy, dated 1/15/24, indicated all injuries of unknown origin require a thorough investigation. It was indicated the person reporting the incident, any witnesses, the resident, and all staff members who had contact with the resident during the period of the alleged incident must be interviewed. All witness reports will be obtained in writing, either the witness will write his or her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him or her sign and date it.
Review of the clinical record indicated that Resident R38 was admitted to the facility on [DATE], with diagnoses which included major depression disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), insomnia (trouble falling and/or staying asleep), schizoaffective disorder (a mental health disorder that is marked by a combination of symptoms, such as hallucinations (an experience in which you see, hear, feel, or smell something that does not exist), depression or mania (mental state of elevated or intense mood and behavior). A review of Resident R38's Minimum Data Set (MDS- a periodic assessment of resident care needs), dated 1/24/24, indicated the diagnoses remained current.
Review of Resident R38's progress note dated 2/21/24, at 12:25 p.m. indicated the resident was transferred from 5 East to 3 East. It was indicated the resident was transferred via wheelchair with an assist of one person to the unit.
Review of Resident R38's progress note dated 2/21/24, at 12:46 p.m. indicated the resident was refusing to eat. The resident complained of left leg pain and would not allow staff to her left leg. The supervisor was notified to evaluate.
Review of Resident R38's progress note dated 2/21/24, at 1:32 p.m. entered by the Director of Nursing (DON), stated Resident R38's left leg was assessed due to pain. It was indicated the left leg appears to be slightly shorter than the right leg and has an outward rotation.
Review of Resident R38's progress note dated 2/21/24, at 8:59 p.m. entered by Registered Nurse (RN) Employee E10 indicated the physician from the hospital called and stated the resident has a hip fracture, and will most likely need surgery.
Review of Resident R38's investigation report dated 2/21/24, stated the patient was assessed due to complaint of pain of left hip. It was indicated the patient was unwilling to allow staff to visualize hip, unable to move extremity and unwilling to do so. A further review of Resident R38's investigation report failed to include signed and dated witness statements from the resident and all staff members who had contact with the resident during the period of the alleged incident.
A review of Resident R38's undated care plan provided by the facility on 3/21/24, indicated the resident had an activities of daily living (ADLS-fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) self-care deficit related to left femur fracture. The resident required extensive assistance of two people with bed mobility, toileting, and transfers.
During an interview on 3/22/24, at 1:53 p.m. the Director of Nursing confirmed that the facility failed to complete an thorough investigation that included signed and dated witness statements from the resident and all staff members who had contact with the resident during the period of the alleged incident for one of six residents (Residents R38).
28 Pa Code: 201.18 (e)(1)(2) Management.
28 Pa Code: 201.29 (a)(c)(d) Resident Rights.
28 Pa Code: 211.12 (a)(c)(d)(1)(3)(5) Nursing services.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, and staff interviews, it was determined that the facility failed to ensure that a compreh...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, and staff interviews, it was determined that the facility failed to ensure that a comprehensive resident care plan was implemented related to post traumatic stress disorder status for one of three residents (Residents R114).
Findings include:
Review of Title 42 Code of Federal Regulations (CFR) §483.21 - Comprehensive Care Plans, the facility must develop and implement a comprehensive care plan for each resident that includes measurable objectives, and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment, and must be culturally competent and trauma informed.
Review of the clinical record revealed that Resident R114 was admitted to the facility on [DATE].
Review of Resident 114's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/13/24, indicated diagnoses of post-traumatic stress disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions), traumatic brain injury (brain dysfunction caused by an outside force), and dementia (neuro-cognitive disorder impacting reasoning, judgment, and memory).
Review of Resident R114's plan of care revealed no care plan was developed to address Resident R114's post-traumatic stress disorder.
During an interview on 3/21/24, at 9:41 a.m. the Registered Nurse Assessment Coordinator Employee E9 confirmed that the facility failed to implement a comprehensive care plan for Resident R114 to address post-traumatic stress disorder.
28 Pa. Code: 211.11(a) Resident care plan.
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 review of facility policy, clinical records, and staff interview it was determined that the facility failed to obtain a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical records, and staff interview it was determined that the facility failed to obtain a physician order and notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as ordered for two out of three residents (Resident R119 and R148).
Findings include:
Review of the clinical record indicated Resident R119 was admitted to the facility on [DATE], with diagnoses that included hemiplegia and hemiparesis following cerebral infarction, dysphasia and atrial fibrillation (irregular and often very rapid heart rhythm).
Review of Resident R119's quarterly MDS assessment(minimum data assessment)- periodic assessment of resident care needs) dated 2/5/24, indicated the diagnosis remained current.
Review of Resident R119 nurse progress dated 1/1/2024 indicated that Resident R119 was sent out to the hospital.
Review of Resident R119's most recent physician order's indicate no order to send resident out to the hospital.
During an interview on 3/21/2024, at 2:23 p.m. the Director of Nursing confirmed that the facility failed to obtain a physcian order (Residents R119).
The Centers for Disease Control defines diabetes as: Diabetes Mellitus is a chronic (long-lasting) health condition that affects how your body turns food into energy. Most of the food you eat is broken down into sugar (also called glucose) and released into your bloodstream. When your blood sugar goes up, it signals your pancreas to release insulin. Insulin acts like a key to let the blood sugar into your body's cells for use as energy. If you have diabetes, your body either doesn't make enough insulin or can't use the insulin it makes as well as it should. When there isn't enough insulin or cells stop responding to insulin, too much blood sugar stays in your bloodstream. Over time, that can cause serious health problems, such as heart disease, vision loss, and kidney disease. Hypoglycemia is a condition that occurs when blood glucose is lower than normal, usually below 70 milligrams per deciliter (mg/dl). If left untreated, hypoglycemia may lead to weakness, confusion, unconsciousness, arrhythmias and even death. People with Diabetes Mellitus may be prescribed injectable insulin to assist in maintaining acceptable levels of CBG's.
The facility Medication and Treatment Orders policy dated 1/15/24, stated orders for medications and treatments will be consistent with principles of safe and effective order writing.
The facility Diabetes-Clinical Protocol policy dated 1/15/24, indicated the physician will order desired parameters for monitoring and reporting information relating to blood sugar management. It was indicated staff will incorporate such parameters into the Medication Administration Record (MAR) and care plan. He resident's blood sugar must be monitored three to four times a day while on a sling-scale insulin.
Review of Resident R148's was admitted to the facility on [DATE], with diagnoses of diabetes (metabolic disorder impacting organ function related to glucose (sugar) levels in the human body) and high blood pressure. Review of Resident R148's MDS assessment (Minimum Data Set assessment: MDS -a periodic assessment of resident care needs) dated 2/29/24, indicated the diagnoses were current.
Review of Resident R148's undated care provided by the facility on 3/21/24, indicated the resident had diabetes and staff must monitor, document, and report any signs and symptoms of high blood glucose.
Review of Resident R148's physician order dated 3/5/24, indicated to administer Novolog (insulin medication used for diabetics to manage blood sugar) subcutaneously (under the skin) via insulin pen with meals using blood glucose monitoring and the following protocol:
70-140=0 units
141-180=1 unit
181-220=2 units
221-260=3 units
261-300=4 units
301-340=6 units
340 or greater =7 units and call the doctor
Review of Resident R148's March 2024 Medication Administration Treatment (MAR) record indicated Resident R148's blood sugar was the following:
459 mg/dl on 3/9/24, at 4:30 p.m.
467 mg/dl on 3/10/24, at 4:30 p.m.
424 mg/dl on 3/12/24, at 4:30 p.m.
364 mg/dl on 3/13/24, at 7:30 a.m.
440 mg/dl on 3/13/24, at 4:30 p.m.
398 mg/dl on 3/15/24, at 4:30 p.m.
374 mg/dl on 3/17/24, at 7:30 a.m.
459 mg/dl on 3/17/24, at 4:30 p.m.
452 mg/dl on 3/19/24, at 4:30 p.m.
Review of Resident R148's progress notes dated 3/9/24, through 3/17/24, failed to include documentation that the physician was notified as ordered of the resident's blood sugar that was above 340 mg/dl.
During an interview on 3/18/24, at 9:35 a.m. Resident R148 indicated he had a concern for his blood sugars. He stated his blood sugar is high, and typically ranges within the 300-400s. He stated that's why I am here, every day it is high.
During an interview on 3/21/24, at 10:04 a.m. Licensed Practical Nurse (LPN), Employee E5 indicated if a resident's blood sugar is above the parameter that is ordered on the sliding scale, then the nurse must administer the amount of insulin ordered, and notify the physician. It was indicated the notification to the physician is documented in a progress note. LPN, Employee E5 confirmed the facility failed to document the physician was notified when Resident R148's blood sugar was above the ordered parameters for the following days:
3/9/24, at 4:30 p.m.
3/10/24, at 4:30 p.m.
3/12/24, at 4:30 p.m.
3/13/24, at 7:30 a.m.
3/13/24, at 4:30 p.m.
3/15/24, at 4:30 p.m.
3/17/24, at 7:30 a.m.
3/17/24, at 4:30 p.m.
3/19/24, at 4:30 p.m.
During an interview on 3/21/24, at 1:22 p.m. the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed the facility failed to notify a physician of abnormal glucose readings via a Capillary Blood Glucose (CBG) level as ordered for one out of three residents (Resident R148).
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, and staff interviews, it was determined that the facility failed to make certain that appro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, and staff interviews, it was determined that the facility failed to make certain that appropriate treatments and services were provided for the monthly change of a urinary catheter for one of five residents (Resident R15).
Findings include:
Review of the facility Catheter Care, Urinary policy dated 1/15/24, indicated the purpose of this policy is to prevent catheter-associated urinary tract infections. When indwelling catheters are changed the date and time the catheter care was given as well as name and title of individual providing catheter care must be documented.
Review of the clinical record indicated that Resident R15 was admitted to the facility on [DATE], with diagnoses that included paraplegia (a specific pattern of paralysis (which is when you can ' t deliberately control or move your muscles) that affects your legs) and stage 4 pressure ulcer (caused by prolonged pressure on the skin and results in skin and tissue loss with exposure of muscle, bones, tendons, or vital organs that develops from prolonged pressure to a direct area.)
A review of Resident R15's Minimum Data Set Assessment (MDS, periodic assessment of resident care needs) dated 2/9/24, indicated the diagnosis were current. Section H- Bladder and Bowel indicated the resident had an indwelling catheter.
A review of Resident R15's progress note dated 12/6/24, stated the resident returned from a appointment yesterday and a new 18 fr cudae (a catheter designed to maneuver around obstructions or blockages in the urethra (tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body)). foley catheter was inserted. PER MD continue with foley orders change foley Monthly.
A review of Resident R15's physician order dated 12/7/23, indicated to change the resident's 16 fr 10cc indwelling foley catheter in the morning every month starting on the 7th for 28 days. The order failed to include the correct size (18 fr cudae) of the catheter. The order was discontinued on 1/15/24.
A review of Resident R15's clinical record failed to include documentation that Resident R15's catheter was changed for the month of January 2024.
A review of Resident R15's physician order dated 2/4/24, indicated to change the resident's 16 fr 10cc indwelling foley catheter in the morning every month starting on the 18th for 28 days. The order failed to include the correct size of the catheter. The order was discontinued on 2/18/24. A review of Resident R15's physician order dated 2/4/24, indicated to change the resident's 16 fr 10cc indwelling foley catheter as needed. The order failed to include the correct size (18 fr cudae) of the catheter.
A review of Resident R15's clinical record failed to include documentation that Resident R15's catheter was changed for the month of February 2024.
During an interview and observation on 3/19/24, at 9:38 p.m. Resident R15 stated They never changed my catheter. I had it about 6-7 months. They tell you they change it whenever it goes bad. I was told you have to have doctor to change. I have asked them to change it, just like anything else around here. There was a large amount of sediment observed in Resident R15's catheter tubing.
During an interview on 3/20/24, at 9:41 a.m. Assistant Director of Nursing, Employee E11 stated catheter changes are normally ordered to be changed monthly. It was indicated there should be an order to change the catheter monthly and as needed. ADON, Employee E11 confirmed Resident R15's order was entered in correctly. ADON, Employee E11 confirmed she was unable to determine when Resident R15's foley catheter was last changed.
Review of Resident R15's undated care plan provided by the facility on 3/21/24, indicated the resident utilizes an indwelling urinary catheter related to urinary retention. It was indicated to change the catheter as per order.
During an interview on 3/21/24, at 1:12 p.m. the Director of Nursing (DON) stated he believed Resident R15's catheter was last changed in December at a Hospital. It was indicated the resident has a difficult anatomy and requires catheter changes to be completed outside of the facility.
During an interview on 3/22/24, at 10:31 a.m. the DON confirmed the facility failed to make certain that appropriate treatments and services were provided for the monthly change of a urinary catheter for one of two residents (Resident R15).
28 Pa Code: 201.14 (a) Responsibility of licensee.
28 Pa code: 211.10 (c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for one of three residents (Resident R107) and securely store oxygen for one of two storage locations.
Findings include:
Review of facility policy Oxygen Administration dated 1/15/24, indicated oxygen therapy via oxygen mask, nasal cannula (a lightweight tube placed in the nostrils to provide oxygen), and/or nasal catheter. Verify that there is a physician order for this procedure. Check that the tubing is connected to the oxygen and assure that it is free of kinks.
Review of the clinical record indicated Resident R107 was admitted to the facility on [DATE].
Review of Resident R107's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/9/24, indicated diagnoses of hypertension (high blood pressure), asthma (condition where the airways narrow and swell), and cancer (a disease caused by an uncontrolled division of abnormal cells in a part of the body).
Review of a physician's active orders dated 1/23/24, indicated to administer oxygen, two to five liters per minute, may titrate oxygen to maintain oxygen saturation greater than 90%. (Normal oxygen saturation is 95 % or above, some people with chronic lung disease can have normal levels around 90%).
Review of Resident R107's active physician orders failed to reveal an order to change oxygen respiratory tubing.
During an observation on 3/18/24, at 11:42 a.m. Resident 107 was sitting on the side of his bed receiving two liters per minute of oxygen via nasal cannula. No date was present on the nasal cannula tubing.
During an interview on 3/18/24, at 1:09 p.m. Licensed Practical Nurse (LPN) Employee E1 confirmed that no date was present on Resident 107 ' s nasal cannula tubing.
During an interview on 3/22/24, at 9:46 a.m. the Director of Nursing confirmed that the facility failed to provide a policy concerning oxygen tubing. DON stated, I cannot find an oxygen tubing policy specifically but the tubing gets changed every Sunday.
During an interview on 3/22/24, at 11:43 a.m. the Director of Nursing confirmed that the facility failed to provide appropriate respiratory care for one of one resident (Resident R107).
During an observation on 3/21/24, at 2:15 p.m. an estimated 140 full oxygen cylinders were observed outside the facility's laundry room behind a fenced in cage that was unsecured and unlocked. There was no lock present on the gate, the oxygen cylinders were easily accessible to anyone.
During an interview on 3/21/24, at 2:35 p.m. the Nursing Home Administrator confirmed the oxygen cylinders that were stored outside the laundry building were not secure and left unlocked. It was indicated maintenance brings in the oxygen cylinders depending on the supply on the floors. The NHA confirmed the facility failed to securely store oxygen for one of two storage locations (Outside Laundry Building).
28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.12(d)(1)(2)(5) Nursing services
28 Pa. Code: 211.12(d)(3) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record review, and staff interviews it was determined that the facility failed to provide a resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical record review, and staff interviews it was determined that the facility failed to provide a resident with necessary behavioral interventions as ordered to maintain the highest practicable mental and psychosocial well-being for one out of eight sampled resident records (Resident R144).
Findings include:
Review of the facility's Behavioral Assessment, Intervention and Monitoring policy dated 1/15/24, indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral health services will be provided by qualified staff who have the competencies and skills necessary to provide appropriate services to the residents.
Review of Resident R144's admission record indicated Resident R144 was admitted on [DATE].
Review of Resident R144's MDS assessment (Minimum Data Set Assessment: A periodic assessment of resident care needs) dated 1/3/24, indicated she was admitted with the following diagnoses that included Depression, high blood pressure, and constipation. Resident R144's MDS assessment section C0200 Brief Interview for Mental Status (BIMS, a screening test that aides in detecting cognitive impairment). The BIMS total score suggests the following distributions: 13-15: cognitively intact, 8-12: moderately impaired, 0-7: severe impairment. Resident R3's BIMS score was a 14 indicating Resident R3 was cognitively intact.
Review of Resident R144's MDS assessment, dated 2/7/24, section D0150 Resident Mood Interview indicated that R144 answered no to the assessment questions. The questions include, Do you have little interest or pleasure in doing things? and Are you feeling down, depressed, or hopeless?
Review of Resident R144's progress note dated 2/15/24, indicated the resident stated he wanted a gun to kill himself. It was indicated the residents family and physician was notified. Nursing was made aware and psychology was consulted.
Review of Resident R144's progress note dated 2/16/24, indicated the resident was seen for a follow-up for palliative care. It was indicated the resident had an episode of saying he wanted a gun to kill himself. It was indicated the patient denied any suicidal ideation or wanting to hurt others. It was indicated the social worker and psych were consulted
Review of Resident R144's clinical record revealed an absence note dated 2/17/24, from the psychological consult. It was indicated the reason for the absent visit was the resident was sleeping.
Review of Resident R144's clinical record failed to reveal any follow-up from psychology after 2/17/24.
During an interview on 3/20/24, at 11:23 a.m. Director of Social Services, Employee E2 indicated if a resident has suicidal ideation, a social worker would evaluate them and consult psychology services as needed. It was indicated if psychology misses a resident's appointment, it is expected that residents are followed up with at the next visit, or staff can ask psych to come sooner if needed. It was indicated psychology services are in the facility weekly to see residents. Director of Social Services, Employee E2 indicated the social work who oversees psych is on vacation.
Review of Resident R144's undated care plan provided by the facility on 3/21/24, indicated the resident was on antidepressant medication due to depression. The care plan failed to include interventions related to the resident's suicidal ideation.
During an interview on 3/21/24, at 9:43 a.m. Registered Nurse Assessment Coordinator (RNAC) Employee E9 confirmed Resident R144's care plan was not update to include his suicidal ideation.
During an interview on 3/21/24 at 10:08 a.m. LPN, Employee E5 confirmed Resident R144 was not followed up by psych since his missed appointment on 2/17/24.
During an interview on 3/21/24, at 1:22 p.m. the Director of Nursing confirmed psychology never followed up with Resident R144, and that the facility failed to provide residents with necessary behavioral healthcare, to maintain the highest practicable mental and psychosocial well-being for Resident R144 as required.
28 Pa. Code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 211.10 (a)(d) Resident care policies.
28 Pa. Code: 211.12 (d)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly monitor food expiration dates on four of five nursing unit food pantri...
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Based on a review of facility policies, observations and staff interviews, it was determined that the facility failed to properly monitor food expiration dates on four of five nursing unit food pantries (Third, Fourth, Fifth, and Sixth Floor Nursing Unit Food Pantries), and properly store utensils for food on one of five nursing units (Fourth Floor) creating the potential for food-borne illness.
Findings include:
Review of facility policy Food Safety Requirements- Use And Storage of Food And Beverage Brought In For Residents, Food Procurement, dated 1/15/24, indicated that food brought into the facility should be properly labeled and dated and will be used within three days or discarded.
Cross contamination refers to the transfer of harmful substances or disease causing microorganisms to food by hands, surfaces, sponges, cloth towels, or utensils which are not cleaned after touching raw food, and then touch ready to eat foods.
Physical Contamination of food are foreign objects that may inadvertently enter the food.
During an observation on 3/21/24, at 11:43 a.m. the Fourth Floor Pantry refrigerator contained two empty plastic containers that had residual amounts of food in them with no label or date, a plastic bowl that contained cabbage with no label or date, a plastic bowl that contained salad with no label or date, a container of mildly thick cranberry juice that was opened and had no date on it, and an ice scoop resting on top of the ice machine.
During an interview on 3/21/24, at 11:46 a.m. Licensed Practical Nurse (LPN) Employee E5 confirmed the above findings.
During an observation on 3/21/24, at 11:50 a.m. the Fifth Floor Pantry Refrigerator contained a bowl of shrimp with no label or date, and a sandwich with no label or date.
During an interview on 3.21.24, at 1:01 p.m. Nurse Aide Employee E6 confirmed the above findings.
During an observation on 3/21/24, at 12:54 p.m. the Third Floor Unit Pantry refrigerator had a plastic picture of apple juice with no date on it.
During an observation on 3/21/24, at 1:07 p.m. the Sixth Floor Pantry refrigerator contained a plastic bag that contained a bowl of fish and vegetables with no label or date, and two pancakes and sausages on a stick that had no label or date, a plastic pitcher of cranberry juice with no date, and a plastic bowl of fruit with no date.
During an interview on 3/21/24, at 1:11 p.m. Nurse Aide Employee E7 confirmed the above findings.
During an interview on 3/21/24, at 2:13 p.m. Dietary Manger Employee E8 confirmed that the facility failed to properly label and monitor food for expiration dates on four out of five nursing units, and failed to prevent physical contamination, and or cross contamination of ice by having an ice scoop on top of the ice machine for one of five nursing units creating the potential for food-borne illness.
28 Pa. Code: 201.14(a) Responsibility of licensee
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 211.6(c) Dietary services.
Jan 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation and resident and staff interview, it was determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation and resident and staff interview, it was determined that the facility failed to provide tracheostomy (tube surgically placed in the windpipe for breathing) care and services consistent with professional standards of practice for one of four residents (Resident R1).
Findings include:
Review of facility policy Tracheostomy Care dated 11/18/23, indicated the tracheostomy care should be provided as often as needed and at least once daily for established tracheostomies.
Review of admission record indicated Resident R1 was admitted to the facility on [DATE].
Review of Resident R1's Minimum Data Set (MDS - periodic assessment of care needs) dated 11/16/23, indicated the diagnoses of respiratory failure (lungs are not getting enough oxygen), high blood pressure, and tracheostomy.
Review of Resident R1's physician orders dated 12/23/23, indicated trach care every night shift and as needed.
Review of Resident R1's care plan dated 11/16/23, indicated to provide trach care every night shift and as needed.
Observation on 1/10/24, at 10:00 a.m. indicated Resident R1 in bed with tracheostomy tube in place, thick yellow/tan secretions bubbling out of trach tube, the gauze around the trach completely saturated in mucous, the inside of the trach mask covered in mucous, and the left upper chest area with hard, dried, yellow/tan secretions.
Interview on 1/10/24, at 10:03 a.m. Licensed Practical Nurse (LPN) Employee E1 indicated I didn't get to her yet and confirmed trach appearance and left upper chest.
Interview with the Director of Nursing on 1/10/24, at 10:04 a.m. confirmed the facility failed to provide tracheostomy care and services consistent with professional standards of practice for one of four residents (Resident R1).
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(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 F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records, facility policy and staff interview, it was determined the facility failed to prov...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records, facility policy and staff interview, it was determined the facility failed to provide consistent and complete communication with the dialysis (treatment that helps body remove extra fluid and waste products) center for 2 of 3 residents (Resident R2 and R3) and failed to have physician orders for care and identification of access sites for two of three residents (Resident R2 and R4).
Findings include:
Review of the facility policy End-Stage Renal disease dated 11/18/23, indicated staff caring for residents with End Stage Renal Disease (ESRD), including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of theses residents. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including how information will be exchanged between facilities.
Review of the facility policy Hemodialysis Access Care dated 11/18/23, indicated the general medical nurse should document in the resident's medical record every shift the location of the catheter, condition of dressing, if dialysis was done during shift, any part of report from dialysis nurse post dialysis being given and observations post dialysis.
Review of physician orders dated 1/7/24, indicated to send dialysis communication form/binder with Resident R2 on dialysis treatment days of Tuesday, Thursday, Saturday.
Review of Resident R2's dialysis communication binder indicated one form with a date of 1/9/2024.
Interview with Licensed Practical Nurse (LPN) Employee E1 on 1/10/24, at 11:30 a.m. indicated a dialysis communication binder is a binder that holds a dialysis communication form. The form is to be completed by facility and sent with the resident to the dialysis center, the dialysis center is to complete the lower portion of form and return in binder to facility.
Interview with LPN Employee E1 confirmed Resident R2 had first dialysis session on Saturday 1/6/24, and a communication form was not available at time of interview.
Review of form dated 1/9/23, indicated it was incomplete as dialysis did not complete their portion.
Review of Resident R3's clinical record indicated readmission date of 2/10/23, with the diagnosis of End Stage Renal Disease (kidneys can't filter waste and excess water) dependence on renal dialysis, and diabetes (high blood sugar).
Review of Resident R3's Minimum Data Set (MDS - a periodic assessment of care needs) dated 10/3/23, Section O indicated dialysis.
Review of physician orders dated 3/23/23, indicated to send dialysis communication form with Resident R3 on dialysis treatment dates.
Review of Resident R3's dialysis communication forms/binder indicated thirty seven forms present, 30 forms were incomplete in the dialysis facility's report to the facility.
Post dialysis information was not completed on communication form for 10/3/23, 10/5/23, 10/7/23, 10/10/23, 10/12/23, 10/14/23, 10/19/23, 10/21/23, 10/26/23, 10/28/23, 10/31/23, 11/4/23, 11/7/23, 11/11/23, 11/14/23, 11/16/23, 11/18/23, 11/25/23, 11/30/23, 12/2/23, 12/5/23, 12/7/23, 12/9/23, 12/12/23, 12/14/23, 12/16/23, 12/19/23, 12/23/23, 12/26/23, 1/4/24, 1/6/24.
During an interview on 1/10/24, at 1:14 p.m. LPN Employee E2 confirmed the dialysis communication sheets were incomplete upon return to the facility.
Review of Resident R4's clinical record indicated readmission date of 12/27/23, with the diagnosis of End Stage Renal Disease, dependence on renal dialysis, and insomnia (trouble sleeping).
Review of Resident R4's MDS dated [DATE], section O indicated dialysis.
Review of Resident R4's physician order dated 12/27/23, indicated dialysis on Tuesday, Thursday, Saturday, and as needed.
Interview with LPN Employee E1, on 1/10/23, 1:06 p.m. indicated unable to locate physician order for Resident R4's dialysis access site or care.
Review of Resident R2's physician orders dated 1/5/24, indicated right subclavian hemodialysis catheter. Check for patency every shift for monitoring.
Review of Resident R2's Admission/readmission Evaluation dated 1/6/24, indicated admission with infusion access site the type of device is a tunneled central line (a thin tube that is placed under the skin in a vein, allowing long term access to the vein).
Interview with LPN Employee E1 on 1/10/23, at 11:30 a.m. when asked how to check patency for Residents R2's right subclavian hemodialysis catheter stated: By law as an LPN, I am not allowed to touch the hemodialysis catheter. LPN Employee E1 when further questioned stated: I do not know who does that.
Interview on 1/10/24, at 1:25 p.m. the Director of Nursing confirmed the facility failed to provide consistent and complete communication with the dialysis center for two of two residents (R2 and R3) and failed to have physician orders for type of dialysis access and monitoring of dialysis access sites for two of three residents (Resident R2 and R4).
28 Pa. Code: §211.5(f) Clinical records.
28 Pa. Code: §211.5(g)(h) Clinical records.
28 Pa. Code: §201.14(a)(e)(1) Management.
28 Pa. Code: §201.14(b)(3) Management.
28 Pa. Code: §211.10(c) Resident care policies.
28 Pa. Code: §211.12(c)(d)(1)(3)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a cl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observations and staff interviews it was determined that the facility failed to provide a clean, safe, comfortable, and homelike environment for four of five resident nursing units (Second floor, third floor, fourth floor, and fifth floor).
Findings include:
The facility Homelike environment policy dated 11/18/23, indicated that residents are provided with a safe, clean, comfortable, and homelike environment. The facility management and staff maximize the characteristics of the facility, these characteristics include a clean, sanitary and orderly environment.
During observations with Maintenance Employee E3 on 1/10/24, the following resident rooms and flooring were observed from 8:55 a.m. - 10:13 a.m.:
-At 8:55 a.m. the second floor nursing unit revealed the hallway, the perimeter (corners and edges) of the hallway, and resident room doorways throughout the unit were covered with dirt and grime appearing as a thick black/grey substance.
-At 9:15 a.m. the third floor nursing unit revealed the hallway, the perimeter of the hallway, and resident room doorways throughout the unit were covered with dirt and grime appearing as a thick black/grey substance.
-At 9:20 a.m. room [ROOM NUMBER]-3012 heating unit under the resident room window revealed dirt, a hair like substance, and two unidentified white circular pills. Observation of the ceiling revealed the privacy curtain track (without curtains) had been dislodged from the ceiling and was not secure above the resident beds. The ceiling by the door had an actual hole where the track had pulled down and was dangling.
-At 9:24 a.m. room [ROOM NUMBER]-3038 had a heating element along the floor with coils exposed.
-At 9:43 a.m. the fourth floor nursing unit revealed the hallway, the perimeter of the hallway, and resident room doorways throughout the unit were covered with dirt and grime appearing as a thick black/grey substance.
-At 10:11 a.m. the fifth floor nursing unit revealed the hallway, the perimeter of the hallway, and resident room doorways throughout the unit were covered with dirt and grime appearing as a thick black/grey substance.
-At 10:13 a.m. room [ROOM NUMBER]-5014 revealed a metal container on the floor that was a mouse trap.
During an interview on 1/10/24, at 10:34 a.m. Maintenance Employee E3 indicated that the hallways and flooring on each unit appeared to be build up, the heating unit in room [ROOM NUMBER]-3012 was dirty and needed cleaned, the privacy curtain track in room [ROOM NUMBER]-3012 was not adhered to the ceiling and a part of the ceiling was missing by the doorway, the heating element along the floor in room [ROOM NUMBER]-3038 should have a cover, and that room [ROOM NUMBER]-5014 had a mouse trap on the floor.
During an interview on 1/10/24, at 10:36 a.m. the Nursing Home Administrator confirmed that the facility failed to provide a clean, comfortable homelike environment for four of five resident nursing units (Second floor, third floor, fourth floor, and fifth floor).
28 Pa. Code 201.14 (g) Responsibility of licensee.
28 Pa. Code 201.18 (e)(1) Management.
Oct 2023
1 deficiency
CONCERN
(F)
📢 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 F0836
(Tag F0836)
Could have caused harm · This affected most or all residents
Based on review of facility financial documents, interview with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' ...
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Based on review of facility financial documents, interview with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are impacted.
Findings include:
28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations subsection 201.14(g), dated July 24, 1999, revealed that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are impacted.
During a review of State Agency provided document, Service Termination Notice to Health Care Facility, dated 10/12/23, from facilities electric service provider, indicated that a termination of service notice was provided due to utility's service bills being overdue in the amount of $40,652.90.
During an interview on 10/31/23, at 8:49 a.m., Nursing Home Administrator (NHA) confirmed that he does not receive service provider bills as they are sent to the corporate office in New Jersey and was unaware that a Service Termination Notice was issued as this would also go to New Jersey.
During an interview on 10/31/23, at 10:15 a.m. NHA stated that he had been in contact with the Corporate Office in New Jersey and was provided documentation that suggested that a check for $30,000 was issued to the electric service provider on 10/18/23.
During an interview with the facility's electric service provider on 10/31/23, at 11:58 a.m., it was revealed that the $30,000 check that the facility stated was issued, had not been received, and that the amount of $30,000 would not be enough to avoid termination of services as a total of $40,652.90 would be required by 11/20/23. It was also stated that the facility had been on payment plan due to previous delinquencies and had an outstanding total balance of $136,302.23. Electric service provider stated that because they have such a large overdue balance, that a payment agreement was made to pay their monthly bill each month plus an additional $13,543.00 for 11 months to be able to pay off the bill. Payment for September ' s bill was due by 9/25/23 and had not been received.
During an interview on 10/31/23, at 1:38 p.m., Regional Manager stated that he was not aware of having received a Service Termination Notice from the electrical provider, however he also stated that he had a conversation with the electrical provider on 10/18/23, regarding payment and had a check issued for $30,000 on 10/18/23, after the conversation. Regional Manager stated that he will have corporate office issue a check today for the $40,652.90 required to avoid termination of services.
During an interview on 10/31/23, at 2:55 p.m., Nursing Home Administrator confirmed that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are impacted.
During an additional interview on 11/2/23, at 1:41 p.m., electrical service provider stated that they have still not received the $30,000 check that the facility stated was issued 10/18/23 and had not yet received the check for $40,652.90. Electrical service provider did state that she was contacted by the facility on 11/2/23, at which time they informed her that they do have the $40,652.90 check issued by corporate office and that this will be mailed.
28 Pa. Code 201.14 (g) Responsibility of licensee.
28 Pa. Code 201.18 (e)(1) Management.
Jul 2023
1 deficiency
CONCERN
(F)
📢 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 F0836
(Tag F0836)
Could have caused harm · This affected most or all residents
Based on review of facility financial documents, interviews with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents'...
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Based on review of facility financial documents, interviews with vendors and staff, it was determined that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are impacted.
Findings include:
28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations subsection 201.14(g), dated July 24, 1999, revealed that a facility owner shall pay in a timely manner bills incurred in the operation of a facility that are not in dispute and that are for services without which the residents' health and safety are impacted.
During a review of State agency provided document, Service Termination Notice to Health Care Facility, dated 6/26/23, from facilities electric service provider, indicated that a termination of service notice was provided due to utility's service bills being overdue in the amount of $86,152.72.
During a review of facility provided documents on 7/6/23, indicated that a check for the overdue amount of $86, 152.72 was issued on 6/28/23, to the electric service provider. Review of an additional facility provided document, Electric service providers monthly statement to facility, indicated an account balance of $234,753.83, requesting an amount of $112,875.53 due 6/26/23. Further review of statement revealed $86,152.72 as the Previous Amount due, and $26,722.81 as the Current Amount due.
During an interview with the facility's electric service provider on 7/6/23, at 11:36 a.m., it was revealed that the facility was in contact with electric provider and that a 30 day hold was placed on the shut off notice until 7/26/23, due to being advised from the facility, that a check for $86,152.72 was issued to satisfy the 10 day shut off notification. Continued discussion with electric provided revealed that monies/check has not been received as of this date and time of interview.
During a follow-up interview with the facility's electric service provider on 7/17/23, at 9:20 a.m., it was revealed that the facility provided 2 checks, in duplicate amounts of $86,152.72, for the monies owed.
Further review of facility provided documents, which included monthly billing statements from other service providers, indicated that an outstanding balance of $123,368.90 dated 6/14/23, was provided to facility from their water service provider. Further review of document from water service provided indicated that $76,404.40 payment was due 7/4/23.
During an interview with the facility's water service provider on 7/6/23, at 11:45 a.m., it was revealed that a 10 day shut off notice was sent to the facility on 6/27/23, due to 3 months of non-payment. Interview further revealed that the facility has until 7/10/23 to contact provider and update plan for payment. Per service provider, facility has not been keeping up to date with current payment plan, further indicating that facility had a $0 balance at the beginning of 2023 year, and that payments were submitted for March and April 2023, however no payments have be submitted since.
Review of additional facility provided document, Special Payment Arrangements, dated 7/17/23, indicated that the water service provider has agreed to allow the facility to pay the balance amount of $123,368.90 over a 10 month period; monthly installments of $11,336,89 are to be remitted with current charges prior to due date, with an initial payment of $10,000.00 to be paid the week of 7/17/23 to begin plan.
During an interview conducted 7/6/23, at 12:07 p.m., Nursing Home Administrator (NHA) stated that he was aware of the shut off notice provided by their electric service provided, however was unaware that the facility was provided with a shut off notice by their water service provider as well.
Further review of facility provided documents, which included information about an additional service provider for nurse service staffing, failed to indicate an outstanding balance or monies past due.
State agency's attempt to obtain information from the facility's gas service provider were unsuccessful.
Review of facility provided Payment Plan Agreement on 7/17/23, indicated that the facility and their gas service provider have entered into a payment agreement plan in which the facility will pay their debt of $93,021.99 in 12 monthly installments of $7,751.83.
During an interview on 7/17/23, at 9:35 a.m., Nursing Home Administrator confirmed that he does not directly see service provider bills (gas, electric, and water) for they are sent to the corporate office in New Jersey.
During an additional interview on 7/17/23, at 12:00 p.m., Nursing Home Administrator confirmed that the facility failed to pay bills in a timely manner for services without which the residents' health and safety are impacted.
28 Pa. Code 201.14 (g) Responsibility of licensee.
28 Pa. Code 201.18 (e)(1) Management.
Mar 2023
8 deficiencies
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, clinical record review, weight documentation, and staff interview it was determined that the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, clinical record review, weight documentation, and staff interview it was determined that the facility failed to obtain weight monitoring documentation for one of five sampled residents (Resident R27).
Findings include:
Review of facility policy Weight Assessment and Intervention, dated 10/29/21, indicated weights will be measured on admission, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Weights will be recorded in the resident's medical record by the 15th of every month. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation.
Review of Resident R27's admission record indicated that she was admitted [DATE], with diagnoses that included epilepsy (a neurological disorder that causes seizures or unusual sensations and behaviors), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and high blood pressure.
A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 1/30/23, indicated that diagnosis remain current upon review.
A review of Resident R27's care plan dated 11/16/22, indicated to monitor weights.
Review of Resident R27's Weight Summary report indicated the following:
10/31/22 - 149.6#
11/28/22 - 150#
12/13/22 - 194.1#
Review of Resident R27's nutrition note dated 12/28/22, indicated that Resident R27 had a significant weight gain of 29.4% (44.1#) in a month. Nutrition note further indicated that the resident's physician was notified, questioned the accuracy of the weight, and that a reweight was needed to confirm.
Review of clinical records, Nurse Practioner note, dated 1/6/23, indicated that Resident R27's appetite is good, weight gain of 41#, and dietitian is requesting a reweigh.
Review of Resident R27's nutrition note dated 2/9/23, indicated no new weight, referencing 12/13/22, weight of 194.1# as most recent weight available.
Review of clinical records, Nurse Practioner note, dated 2/3/23, and 3/3/23, indicated no recent weight available.
During an interview on 3/10/23, at 11:30 p.m., Registered Dietitian (RD) Employee E6 confirmed that the facility failed to obtain weight monitoring documentation for Resident R27 as required.
28 Pa Code: 211.10 (c )(d) Resident care policies
28 Pa Code: 211.12 (d )(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation and resident and staff interview, it was determined that the facility failed to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, observation and resident and staff interview, it was determined that the facility failed to provide tracheostomy (a tube surgically placed in the windpipe for breathing) care and services consistent with professional standards of practice for one of seven newly admitted residents (Resident R13).
Findings include:
Review of admission record indicated Resident R13 was re-admitted to the facility on [DATE].
Review of facility policy Tracheostomy Care dated 1/15/23, indicated the tracheostomy care should be provided as often as needed and at least once daily for established tracheostomies.
Review of Resident R13's Minimum Data Set (MDS - periodic assessment of care needs) dated 12/7/22, indicated the diagnoses of heart failure (heart doesn ' t pump blood as well as it should) , respiratory failure (lungs are not getting enough oxygen), and tracheostomy.
Review of Resident R13's physician orders dated 3/2/23, the day of re-admission to the facility, indicated no order for tracheostomy care.
Review of Resident R13's care plan dated 3/8/23, failed to reveal required interventions related to inner cannula replacement and changes.
Observation on 3/8/23, at 10:31 a.m. indicated Resident R13 in bed with tracheostomy tube in place.
Interview on 3/8/23, at 10:32 a.m. Resident R13 indicated staff had not changed her disposable inner cannula since return from the hospital on 3/2/23, and not daily as required.
Interview with the Director of Nursing on 3/8/23, at 11:00 a.m. stated, You caught us, she re-admitted at the end of last week and we haven't had a chance to triple check her chart and confirmed
the facility failed to provide tracheostomy care and services consistent with professional standards of practice for one of seven newly admitted residents (Resident R13).
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(3)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected multiple residents
Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a c...
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Based on review of the Minimum Data Set (MDS-periodic assessment of resident care needs) User's Manual, clinical record, and staff interview, it was determined that the facility failed to complete a comprehensive assessment after a significant change in condition for two of five residents receiving hospice services (Resident R31 and R111).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The Assessment Reference Date (ARD) must be within 14-days from effective date of the hospice election.
A review of Resident R31's clinical record revealed an admission date of 11/1/21, with diagnoses that included chronic obstructive pulmonary disease, diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and depression.
A review of Resident R31's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 1/18/23, indicated that diagnoses remain current upon review.
A review of the clinical record revealed a physician's order, dated 2/8/23, indicating that hospice services were initiated for Resident R31.
Further review of the clinical record failed to indicate documented evidence that a significant change MDS with an ARD completed within 14-days from when Resident R31 was admitted to hospice care was completed.
A review of Resident R111's clinical record revealed an admission date of 8/25/21, with diagnoses that included dementia (a group of symptoms that affects memory, thinking and interferes with daily life), high blood pressure, and depression.
A review of Resident R111's MDS assessment (MDS-Minimum Data Set assessment: periodic assessment of resident care needs) dated 1/25/23, indicated that diagnoses remain current upon review.
A review of the clinical record revealed a physician's order, dated 2/16/23, indicating that hospice services were initiated for Resident R111.
Further review of the clinical record failed to indicate documented evidence that a significant change MDS with an ARD completed within 14-days from when Resident R11 was admitted to hospice care was completed.
During an interview on 3/10/23, at 1:10 p.m., Director of Nursing (DON) confirmed that the facility failed to complete a comprehensive assessment after a significant change in condition for two of five residents receiving hospice services (Resident R31 and R111).
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.5(f) Clinical Records
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interview, it was determined that the facility failed to provide proper ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interview, it was determined that the facility failed to provide proper Activities of Daily Living (ADL) assistance with eating and timely incontinence care for one of 16 residents (Resident R151), assistance with bathing for two of 16 residents (Resident R51 and R92) and lack of fingernail care for one of 16 residents (Resident R65).
Findings include:
Review of the facility policy Activities of Daily Living (ADLs), Supporting dated 1/15/23, indicated appropriate care and services will be provided for residents who are unable to carry out ADLs independently, including appropriate support and assistance with hygiene (bathing and dressing), elimination (toileting), and dining (meals and snacks).
Review of the admission record indicated Resident R151 was admitted to the facility on [DATE].
Review of Resident R151's Minimum Data Set (MDS- periodic review of care needs) dated 12/7/22, indicated the diagnoses of high blood pressure, urinary tract infection, quadriplegia (paralysis of all four limbs).
Review of Resident R151's ADL self-care deficit care plan dated 1/11/23, indicated total dependence required with bathing, bed mobility, dressing, eating, hygiene and grooming, and toileting.
Observation of Resident R151 on 3/6/23, at 1:18 p.m. indicated an uncovered condom catheter (external catheter used for urinary drainage) on the floor beside the bed attached to a urinary drainage bag and a strong odor of urine in the room.
Interview with Resident R151 on 3/6/23, at 1:19 p.m. indicated the catheter came off this morning before 9:00 a.m., that he was wet at the time of the interview and had not been changed since before 9:00 a.m. this morning. He stated the Nursing Assistant (NA) Employee E4 came into the room and he requested to be changed but at the time NA Employee E4 had his lunch tray and proceeded to feed him while he was soiled in urine.
Interview on 3/6/23, at 1:39 p.m. NA Employee E4 indicated resident R151 was washed that morning before 9:00 a.m. and required a complete bed change because the catheter had come off and that at lunch Resident R151 asked to be changed, but NA Employee E4 already had the food, and proceeded to feed resident. Stated He wasn't soiled when I fed him, just wet.
Review of admission record indicated Resident R51 was admitted to the facility on [DATE].
Review of Resident R51's MDS dated [DATE] indicated diagnoses of atrial fibrillation (irregular heart rhythm), heart failure (heart doesn't pump blood as well as it should), and high blood pressure. Section
G indicated total dependence for personal hygiene and bathing.
Review of Resident R51's task document titled Bath/Shower - Wednesday/Saturday evenings dated from 2/8/23 - 3/4/23 indicated no evidence of a bath or shower.
Observation on 3/6/21, at 10:25 a.m. indicated Resident R51's hair was unkempt, greasy, and facial hair present on female.
Review of admission record indicated Resident R92 was admitted to the facility on [DATE].
Review of Resident R92's MDS dated [DATE] indicated diagnoses of Alzheimer's disease (progressive disease that destroys memory), osteoarthritis (brittle bones), and malnutrition (lack of nutrition). Section G indicated total dependence for personal hygiene and bathing.
Review of Resident R92's task document titled Bath/Shower - Tuesday/Friday evenings dated from 2/7/23 - 3/3/23 indicated no evidence of a bath or shower.
Observation on 3/7/23, at 2:05 p.m. indicated Resident R92's mouth was dry with cracked lips and facial hair on a female resident.
Interview on 3/7/23, at 2:06 p.m. NA Employee E5 confirmed Resident R92's lips were dried and cracked and facial hair was present.
Review of admission record indicated Resident R65 was admitted to the facility on [DATE].
Review of Resident R65's MDS dated [DATE] indicated the diagnoses of anemia (the blood doesn ' t have enough health red blood cells), high blood pressure, and stroke. Section G indicated extensive assistance of one staff for personal hygiene.
Observation on 3/8/23, at 12:21 p.m. indicated long fingernails with debris underneath.
Interview with Resident R65 and Licensed Practical Nurse (LPN) Employee E3 indicated Resident R65would like to have assistance with cutting his nails.
Interview on 3/10/23, at 3:00 p.m. the Director of Nursing confirmed the facility failed to provide proper Activities of Daily Living (ADL) assistance with eating and timely incontinence care for one of 16 residents (Resident R151), assistance with bathing for two of 16 residents (Resident R51 and R92) and lack of fingernail care for one of 16 residents (Resident R65).
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code: 211.12(d)(3)(5) Nursing services.
28 Pa. Code: 201.29(d) Resident rights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, observations, and staff interviews it was determined that the facility failed to assure that licensed nurses demonstrated competencies and skills nece...
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Based on review of policies and clinical records, observations, and staff interviews it was determined that the facility failed to assure that licensed nurses demonstrated competencies and skills necessary to administer medications for five of 14 residents (Resident R2, R30, R59, R95, and R109).
Review of the facility policy Administering Medications dated 1/15/23, indicated that medications are administered in a safe manner.
During an observation of a medication administration on 3/10/23, at 8:05 a.m. LPN Employee E2 was observed with five medication cups stacked, one on top of the other, in her hands. One of the medication cups was labeled with a name, the remaining four were unlabeled.
During an interview on 3/10/23, at 8:06 a.m. LPN Employee E2 stated the medications were for Resident R2, R30, R59, R95, and R109. Only the medication cup for R59 was labeled. When asked why she had pre-poured the medications, she stated that if she moved the medication cart away from the power supply, it would shut off.
During an interview on 3/10/23, at 9:15 a.m. the Director of Nursing confirmed that the facility failed to assure that licensed nurses demonstrated competencies and skills necessary to administer medications for five of 14 residents.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility document review and staff interviews, it was determined that the facility failed to maintain an ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility document review and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program, which ensured proper cleaning and disinfecting of glucometers (a device used to test the amount of sugar in a person's blood) to prevent the potential for cross-contamination and failed to properly complete dressing changes for three of six residents observed (Resident R18, R13, R65, and R107) as required.
Findings include:
Review of the facility policy titled Blood Sampling - Capillary (Finger Sticks) dated 1/15/23, indicated that staff should always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses.
Review of the facility policy Wound Care dated 1/15/23, indicated staff will utilize their policy to for the care of wounds to promote healing.
Review of the Centers for Disease Control and Prevention's document titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration last reviewed 3/2/11, indicated that if blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents.
Review of admission record indicated the Resident R18 was admitted to the facility on [DATE].
Review of Resident R18's Minimum Data Set (MDS- periodic assessment of care needs) dated 2/6/23, indicated the diagnoses of high blood pressure, diabetes (too much sugar in the blood), and traumatic brain injury (brain dysfunction caused by an outside force, usually a violent blow to the head).
Observation of Resident R18's blood sugar check on 3/8/23, at 12:02 p.m., Licensed Practical Nurse (LPN) Employee E3 failed to clean the glucometer before or after use with a germicidal wipe.
Review of admission record indicated Resident R13 was admitted to the facility on [DATE].
Review of the MDS dated [DATE], indicated the diagnoses of heart failure (heart doesn ' t pump blood as well as it should), respiratory failure (a serious condition that makes it difficult to breathe on your own), and tracheostomy (a tube inserted into the windpipe through the neck for breathing).
Observation of Resident R13' blood sugar check on 3/8/23, at 12:12 p.m. LPN Employee E3 failed to clean the glucometer before or after use with a germicidal wipe.
Review of admission record indicated Resident R65 was admitted to the facility on [DATE].
Review of Resident R65's MDS dated [DATE] indicated the diagnoses of anemia (the blood doesn ' t have enough health red blood cells), high blood pressure, and stroke.
Observation of Resident R65' blood sugar check on 3/8/23, at 12:21 p.m. LPN Employee E3 failed to clean the glucometer before or after use with a germicidal wipe.
During an observation of a dressing change for Resident R107 on 3/9/23, at 12:00 p.m. the following was observed:
-Licensed Practical Nurse (LPN) Employee E1 cleansed the bedside table with gloved hands and placed a disposable cloth on it for a clean field. LPN Employee E1 then proceeded to open and place dressing changes supplies on the field without changing her gloves, touching the sterile gauze with the gloves that had disinfectant on them.
-LPN Employee E1 used the contaminated gauze to clean the wound.
-LPN Employee E1 dated the dressing by writing on the dressing after it had been applied to the resident.
-The wound dressing had been completed with a brief wet with urine folded down, and when the dressing change was completed, the wet brief was refastened, not replaced.
During an interview on 3/8/23, at 2:00 p.m. the Director of Nursing confirmed the facility failed to maintain an infection prevention and control program, which ensured proper cleaning and disinfecting of glucometers to prevent the potential for cross-contamination and failed to properly complete dressing changes for four of six residents observed (Resident R18, R13, R65, and R107) as required.
28 Pa. Code: §211.10(c) Resident care policies.
28 Pa. Code: §211.12(c)(d)(1)(3)(5) Nursing services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0838
(Tag F0838)
Could have caused harm · This affected most or all residents
Based on review of facility documents and staff interview it was determined that the facility failed to complete the Facility Assessment annually.
Findings include:
A review of the Facility Assessmen...
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Based on review of facility documents and staff interview it was determined that the facility failed to complete the Facility Assessment annually.
Findings include:
A review of the Facility Assessment Tool, dated 12/15/22, revealed the facility did not individualize the template to indicate accurate information on:
-Ethnic, cultural, or religious factors: no information was provided in this section.
-Care required by the resident population: information was included on ventilator care, which is not provided by the facility.
-Facility Resources: Information was included on respiratory care staff which are not employed by the facility. Information was not included on: staff assignments, policies for the provision of care, working with medical practitioners.
-Physical Environment: No contracts, memorandum of understanding, or third-party agreements provided with Facility Assessment for services not directly provided by the facility or in the instance of emergency.
-Health Information: No information was provided on electronic record management.
-A facility-based and community-based risk assessment was not provided.
During an interview on 3/10/23, at 12:30 p.m. the Nursing Home Administrator confirmed that the facility failed to complete the Facility Assessment document as necessary.
28 Pa. Code 201.18(b)(3)(e)(2) Management.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
Based on review of facility documentation and staff interview, it was determined that the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - a form provided to ...
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Based on review of facility documentation and staff interview, it was determined that the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - a form provided to residents when the facility identifies that services may not be covered by Medicare which includes choices for continuation or discontinuation of services) that included sufficient information to make an informed decision for two of three residents reviewed (Resident R147 and Closed Record CR1).
Findings include:
Review of instructions for the completion of an SNFABN indicated that the form was to be provided to residents by the facility when services provided may not be covered by Medicare. The instructions indicated that the SNFABN provided information to the beneficiary (resident receiving services) so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume the financial responsibility. All sections are to be completed including the specific service/care in question, the reason why the service/care may not be covered, and the estimated cost of the care.
A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form completed by the facility revealed that Resident R147's last covered day of Medicare coverage was 9/9/22. The SNF ABN form indicated that Medicare would probably not pay for therapy services; however, there was no documented evidence that Resident R147 was provided with specific service/care in question, the reason why the service/care may not be covered, and the estimated cost of the care to continue therapy services.
A Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form completed by the facility revealed that Resident CR1's last covered day of Medicare coverage was 12/5/22. The SNF ABN form indicated that Medicare would probably not pay for therapy services; however, there was no documented evidence that Resident R42 was provided with specific service/care in question, the reason why the service/care may not be covered, and the estimated cost of the care to continue therapy services.
During an interview on 3/8/23, at 9:30 a.m., Nursing Home Administrator confirmed that the facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN - a form provided to residents when the facility identifies that services may not be covered by Medicare which includes choices for continuation or discontinuation of services) that included sufficient information to make an informed decision for two of three residents reviewed (Resident R147 and Closed Record CR1).
28 Pa. Code 201.18(e)(1) Management.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), $137,886 in fines. Review inspection reports carefully.
- • 51 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $137,886 in fines. Extremely high, among the most fined facilities in Pennsylvania. Major compliance failures.
- • Grade F (0/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is Corner View's CMS Rating?
CMS assigns CORNER VIEW NURSING AND REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Corner View Staffed?
CMS rates CORNER VIEW NURSING AND REHABILITATION CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes.
What Have Inspectors Found at Corner View?
State health inspectors documented 51 deficiencies at CORNER VIEW NURSING AND REHABILITATION CENTER during 2023 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 48 with potential for harm, and 2 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Corner View?
CORNER VIEW NURSING AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 187 certified beds and approximately 147 residents (about 79% occupancy), it is a mid-sized facility located in PITTSBURGH, Pennsylvania.
How Does Corner View Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, CORNER VIEW NURSING AND REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.0 and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Corner View?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the substantiated abuse finding on record.
Is Corner View Safe?
Based on CMS inspection data, CORNER VIEW NURSING AND REHABILITATION CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Corner View Stick Around?
CORNER VIEW NURSING AND REHABILITATION CENTER has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Corner View Ever Fined?
CORNER VIEW NURSING AND REHABILITATION CENTER has been fined $137,886 across 2 penalty actions. This is 4.0x the Pennsylvania average of $34,458. Fines at this level are uncommon and typically indicate a pattern of serious deficiencies, repeated violations, or failure to correct problems promptly. CMS reserves penalties of this magnitude for facilities that pose significant, documented risk to resident health or safety. Families should request specific documentation of what issues led to these fines and what systemic changes have been implemented.
Is Corner View on Any Federal Watch List?
CORNER VIEW NURSING AND REHABILITATION 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.