SCOTTDALE HEALTHCARE & REHABILITATION CENTER
For profit - Corporation
35 Beds
BONAMOUR HEALTH GROUP
Data: November 2025
Trust Grade
45/100
#490 of 653 in PA
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Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Scottdale Healthcare & Rehabilitation Center has a Trust Grade of D, which indicates below-average performance with some concerns about care quality. They rank #490 out of 653 facilities in Pennsylvania, placing them in the bottom half, and #9 out of 18 in Westmoreland County, meaning there are only a few local options that are better. The facility is showing improvement, with the number of issues decreasing from 34 in 2023 to 18 in 2024. Staffing appears to be a strength, with a 4/5 star rating and a lower-than-average RN turnover of 61%, though this is still concerning compared to the state average. While there have been no fines reported, there are significant concerns, including failures to report allegations of abuse promptly and not notifying families about hospital transfers for multiple residents.
- Trust Score
- D
- In Pennsylvania
- #490/653
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ✓ Good
- Each resident gets 75 minutes of Registered Nurse (RN) attention daily — more than 97% of Pennsylvania nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 53 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Bottom 25%
No red flags
34 → 18 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 34 issues
2024: 18 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Pennsylvania average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 61%
15pts above Pennsylvania avg (46%)
Frequent staff changes - ask about care continuity
Chain: BONAMOUR HEALTH GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (61%)
13 points above Pennsylvania average of 48%
The Ugly 53 deficiencies on record
Nov 2024
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was de...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that comprehensive admission Minimum Data Set assessments were completed in the required timeframe for four of 30 residents reviewed (Residents 181, 182, 183, 184).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that an admission MDS assessment was to be completed no later than 14 days (admission date + 13 calendar days) following admission.
A comprehensive admission MDS assessment for Resident 181, dated July 29, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on August 7, 2024, which was 16 days after admission.
A comprehensive admission MDS assessment for Resident 182, dated August 11, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on August 19, 2024, which was 15 days after admission.
A comprehensive admission MDS assessment for Resident 183, dated August 18, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on August 26, 2024, which was 15 days after admission.
A comprehensive admission MDS assessment for Resident 184, dated June 18, 2024, revealed that the resident was admitted to the facility on [DATE], and the resident's admission MDS assessment was dated as completed on June 26, 2024, which was 15 days after admission.
An interview with the Regional Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on November 14, 2024, at 1:44 p.m. confirmed that Residents 181, 182, 183 and 184's admission MDS assessments were not completed within the required time frames.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set ass...
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Based on review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for four of 30 residents reviewed (Resident 10, 11, 18, 29).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days.
A quarterly MDS assessment for Resident 10 had an ARD of August 9, 2024, which was 93 days after the previous quarterly MDS assessment with an ARD of May 8, 2024.
A quarterly MDS assessment for Resident 11 had an ARD of August 3, 2024, but it was not completed (Section Z0500B) until August 19, 2024, which was two days late.
A quarterly MDS assessment for Resident 18 had an ARD of August 2, 2024, but it was not completed (Section Z0500B) until August 19, 2024, which was three days late.
A quarterly MDS assessment for Resident 29 had an ARD of August 4, 2024, which was 93 days after the previous quarterly MDS assessment with an ARD of May 3, 2024.
An interview with the Regional Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on November 14, 2024, at 1:44 p.m. confirmed that the above referenced quarterly MDS assessments were not completed within the required time frames.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set ...
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Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for three of 30 residents reviewed (Residents 5, 22, 23).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (required assessments of a resident's abilities and care needs), dated October 2024, revealed that Section N0415J1 Hypoglycemic Medications was to be coded if the resident took hypoglycemic medication during the seven-day look-back period and Section N0415K1 was to be coded if the resident took anticonvulsant medication during the seven-day look-back period
Physician's orders for Resident 5, dated October 3, 2024, included orders for the resident to receive 500 milligrams (mg) of Metformin (medication used to lower blood sugars) one time a day for diabetes. There was no physician's order for the resident to receive an anticonvulsant medication.
Review of the Medication Administration Record (MAR) for Resident 5, dated October 2024, revealed that staff had administered the Metformin during the seven-day look-back period.
A quarterly MDS assessment for Resident 5, dated October 9, 2024, revealed that Section N0415J1 was not coded, indicating that the resident did not receive hypoglycemic medication during the seven-day look-back assessment period and Section N0415K1 was coded, indicating that the resident received an anticonvulsant medication during the seven-day look-back period.
Interview with the Regional Registered Nurse Assessment Coordinator on November 14, 2024, at 12:20 p.m. confirmed that Resident 5 received a hypoglycemic medication during the look-back period, did not receive an anticonvulsant medication during the look-back period, and that the assessment was coded inaccurately.
The RAI User's Manual, dated October 2024, indicated that the intent of Section N was to record the number of days during the seven days of the assessment period that any type of injection, insulin, and/or select medications were received by the resident.
An admission MDS assessment for Resident 22, dated October 4, 2024, revealed that Section N0300 indicated that the resident received an injection on one day of the assessment period.
A review of Resident 22's Medication Administration Record (MAR) for September and October 2024 revealed that the resident did not receive any injections.
Interview with the Regional Registered Nurse Assessment Coordinator on November 14, 2024, at 12:18 p.m. confirmed that Resident 22 did not receive an injection during the look-back period and that the assessment was coded inaccurately.
The RAI User's Manual, dated October 2023, revealed that Section N0415E1 (Anticoagulant Medications - medications that thin the blood) was to be coded if the resident received an anticoagulant medication during the seven-day assessment period; Section N0415H1 Opioid Medications (narcotic medications used to treat pain) was to be coded if the resident used an opioid during the seven-day assessment period; and Section N0415K1 (Anticonvulsant Medications- used to treat seizure disorder) was to be coded if the resident used an anticonvulsant during the seven-day assessment period.
Physician's orders for Resident 23, dated October 8, 2024, included orders for the resident to receive 40 mg of Enoxaparin (an anticoagulant medication) subcutaneously (beneath the skin) one time a day and 5-325 mg of Percocet (a narcotic pain medication) every four hours as needed for pain. There was no physician's order for an anticonvulsant medication. The resident's MAR for October 2024 revealed that the resident received Enoxaparin and Percocet during the assessment's look-back period.
A significant change MDS assessment for Resident 23, dated October 14, 2024, revealed that sections N0415E1 and N0415J1 were not coded, indicating that the resident did not receive anticoagulant and opioid medications during the seven-day look-back assessment period, and Section N0415K1 was coded, indicating that the resident received an anticonvulsant medication during the seven-day look-back assessment period.
Interview with the Regional Registered Nurse Assessment Coordinator on November 14, 2024, at 12:20 p.m. confirmed that Resident 23 received anticoagulant and opioid medications, did not receive an anticonvulsant medication during the look-back period, and that the assessment was coded inaccurately.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address the care needs of one of 30 residents reviewed (Resident 5).
Findings include:
A facility policy for Comprehensive Person-Centered Care Plans, dated December 7, 2023, included that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 9, 2024, revealed that the resident was moderately cognitively impaired, was always incontinent of urine, and received an antibiotic.
Physician's orders, dated July 24, 2024, included orders for the resident to receive 100 milligrams (mg) of Macrobid (an antibiotic) twice a day for five days for a urinary tract infection (UTI). Physician's orders, dated August 4, 2024, included orders for the resident to receive 500 mg of Keflex (an antibiotic) four times a day for 10 days for a UTI. Physician's orders, dated October 19, 2024, included orders for the resident to receive 500 mg of Keflex (an antibiotic) one time a day for seven days for a UTI.
A nursing note, dated October 19, 2024, at 12:43 p.m., revealed that Resident 5's daughter was concerned about the resident's frequent UTI's.
There was no documented evidence that a care plan was developed to address Resident 5's specific and individualized care needs related to frequent UTI's.
Interview with the Director of Nursing on November 14, 2024, at 1:45 p.m. confirmed that an individualized care plan and interventions were not developed related to Resident 5's frequent UTI's.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of facility polices and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect t...
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Based on review of facility polices and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for one of 30 residents reviewed (Resident 16).
Findings include:
A facility policy for Comprehensive Person-Centered Care Plans, dated December 7, 2023, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and resident's condition change.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated September 10, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received dialysis (treatment to remove extra fluid and waste from the blood when the kidneys are not able to), and had a diagnosis of end-stage renal disease (ESRD-kidneys no longer work as they should to meet the body's needs requiring dialysis or kidney transplant).
A review of Resident 16's clinical record and dialysis communication records indicated that the resident received dialysis on Mondays, Wednesdays, and Fridays; however, the care plan for Resident 16, dated December 21, 2023, indicated that she attended dialysis on Tuesdays, Thursdays, and Saturdays.
Interview with the Director of Nursing on November 14, 2024, at 9:25 a.m. confirmed that Resident 16's care plan was not revised to reflect that the resident received dialysis on Mondays, Wednesdays, and Fridays and it should have been.
28 Pa. Code 201.24(e)(4) admission Policy.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place to preven...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that interventions were in place to prevent urinary tract infections for one of 30 residents reviewed (Resident 15) who had an indwelling urinary catheter.
Findings include:
The facility's policy regarding indwelling urinary catheters (a flexible tube inserted and held in the bladder to drain urine), dated December 7, 2023, revealed that indwelling urinary catheters would be used sparingly, for appropriate indications only. If an indwelling urinary catheter was needed, staff would monitor for and report complications such as evidence of symptomatic infection.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated October 30, 2024, revealed that the resident was cognitively intact and had an indwelling urinary catheter. A diagnosis record, dated November 2024, revealed the resident had a diagnosis of urinary retention.
Physician's orders for Resident 15, dated October 24, 2024, included an order for the resident to have an indwelling urinary catheter due to neurogenic bladder (a condition that causes loss of bladder control due to damage to the nervous system), and it was to be changed every 30 days for dislodgement or blockage and as needed. A care plan, dated October 28, 2024, indicated that staff were to secure the resident's catheter with a securement device.
Observations of Resident 15 on November 12, 2024, at 10:53 a.m. revealed that the resident was in his wheelchair and his catheter tubing was lying on the fall mat. Staff entered the room to give the resident a flu shot and left the room without repositioning the catheter tubing.
Interviews with the Director of Nursing on November 12, 2024, at 2:58 p.m. confirmed that Resident 15's catheter tubing should not have been in contact with the fall mat.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure there was a physician's order to receive dialysis for one of 30 residents reviewed (Resident...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure there was a physician's order to receive dialysis for one of 30 residents reviewed (Resident 16) who required dialysis.
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 16, dated September 10, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received dialysis (treatment to remove extra fluid and waste from the blood when the kidneys are not able to), and had a diagnosis of end-stage renal disease (ESRD - kidneys no longer work as they should, requiring dialysis or kidney transplant).
A review of Resident 16's clinical record and dialysis communication records revealed that the resident received dialysis treatment every Monday, Wednesday, and Friday. A care plan for Resident 16, dated December 21, 2023, indicated that the resident received dialysis services; however, there was no documented evidence in Resident 16's clinical record of an active physician's order for the resident to attend dialysis.
Interview with the Director of Nursing on November 14, 2024, at 9:25 a.m. confirmed that there was no documented evidence in Resident 16's clinical record of an active physician's order for the resident to attend dialysis and there should have been.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medi...
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Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary psychotropic medications, by failing to ensure that non-pharmacological (non-medication) behavioral interventions (individualized, non-pharmacological approaches to care), were attempted prior to the administration of as needed antianxiety medications for one of 30 residents reviewed (Resident 12).
Findings include:
The facility's policy regarding psychotropic medications (any medication that affects brain activities associated with mental processes and behavior), dated December 7, 2023, indicated that non-pharmacological approaches are used (unless contraindicated) to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 19, 2024, indicated that the resident was cognitively intact, was understood and able to understand others, required assistance with care needs, received antianxiety and opioid medications, was receiving oxygen therapy and hospice services, and had a diagnosis of congestive heart (the heart cannot pump blood well enough to meet the body's needs).
Physician's orders for Resident 12, dated September 11, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (Lorazepam) (a controlled antianxiety medication) every four hours as needed for anxiety/ restlessness.
Review of the Medication Administration Record (MAR) for Resident 12 for September and October 2024 revealed that the resident was administered 0.5 mg of Ativan on September 14 at 10:47 p.m., September 15 at 5:11 p.m. and 11:02 p.m., September 21 at 10:07 p.m., September 24 at 12:17 a.m., September 29 at 8:44 p.m., October 1 at 10:01 p.m., and October 2 at 9:28 p.m. There was no documented evidence that non-pharmacological behavioral interventions were attempted prior to administering Ativan on the above-mentioned dates and times.
Interview with the Director of Nursing on November 13, 2024, at 1:33 p.m. confirmed that non-pharmacological interventions should have been attempted prior to the administration of as needed Ativan to Resident 12 on the above-mentioned dates and times.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed, resulting in significant medication errors for one of...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders were followed, resulting in significant medication errors for one of 30 residents reviewed (Resident 15).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated October 30, 2024, revealed that the resident was cognitively intact, received an anticoagulant (blood thinner), and had diagnoses that included atrial fibrillation (an abnormal heart rhythm).
Physician's orders for Resident 15, dated October 25, 2024, included an order for the resident to receive 3 milligrams (mg) of warfarin (blood thinning medication) daily for atrial fibrillation. However, the resident's Medication Administration Record for October 25, 2024, revealed that staff did not administer 3 mg of warfarin daily as ordered.
Physician's orders, dated October 28, 2024, included an order for the resident to receive 6 mg of warfarin at bedtime then 3 mg of warfarin on Tuesday October 29, 2024. However, the resident's Medication Administration Record for October 28, 2024, revealed that staff administered 9 mg of warfarin.
Physician's orders, dated October 29, 2024, included an order for the resident's PT/INR (prothrombin/ international normalized ratio- test to determine clotting time) be drawn. The PT/INR flow sheet for warfarin, dated October 30, 2024, indicated that the resident's INR was 2.3 (therapeutic range of 2 to 3) and the resident was to receive 3 mg of warfarin. However, there was no documented evidence of a physician's order to administer 3 mg of warfarin on October 30, 2024, and the resident's Medication Administration Record for October 30, 2024, revealed that staff did not administer 3 mg of warfarin.
Interview with the Director of Nursing on November 13, 2024, at 1:55 p.m. confirmed staff should have administered 3 mg warfarin on October 25 and 30, 2024, and administered the wrong dose of warfarin on October 28, 2024.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) survey ending December 20, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility-maintained compliance with cited nursing home regulations. The results of the current survey, ending November 14, 2024, identified repeated deficiencies related to a failure to develop comprehensive care plans, to update resident care plans, to follow physician's orders, to account for controlled medications, and following proper infection control practices.
The facility's plan of correction for a deficiency regarding developing comprehensive care plans, cited during the survey ending December 20, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F656, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the development of comprehensive care plans.
The facility's plan of correction for a deficiency regarding a failure to update resident care plans, cited during the survey ending December 20, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding updating residents' care plans.
The facility's plans of correction for deficiencies regarding failure to follow physician's orders, cited during the survey ending December 20, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding following physician's orders.
The facility's plan of correction for a deficiency regarding the failure to account for controlled medications, cited during the survey ending December 20, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in correcting deficient practices related to the accountability of controlled medications.
The facility's plan of correction for a deficiency regarding following infection control practices, cited during the survey ending December 20, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding following infection control practices.
Refer to F656, F657, F684, F755, F880.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed ...
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Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for two of 31 residents reviewed (Residents 9, 14).
Findings include:
CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.
The facility's policy regarding EBP, dated December 7, 2023, revealed that EBP's are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with a CDC targeted or epidemiologically important MDRO, including Extended Spectrum Beta Lactamase (ESBL)-producing Enterobacterales. EBP's remain in place for the duration of the resident's stay. Signs are posted in the door or on the wall outside of the resident's room indicating the type of precautions and PPE required. PPE is available outside of the resident's rooms.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated September 13, 2024, indicated that the resident was cognitively intact, was understood and able to understand what was being said, required assistance with care needs, was occasionally incontinent of urine, and had diagnoses that included lung cancer and chronic obstructive pulmonary disease (COPD) (chronic lung disease making breathing difficult).
A physician's progress note for Resident 9, dated May 13, 2024, at 9:29 p.m., indicated that the resident's final urine culture showed that the resident had Extended Spectrum Beta Lactamase (ESBL) (an infection that makes bacteria resistant to many antibiotics) and was not susceptible to the Keflex (antibiotic) that was ordered and was ordered to receive intravenous (administration of fluids and/or medications directly into a person's vein) antibiotics.
Observations during the facility tour on November 13, 2024, at 8:30 a.m. revealed that Resident 9 was lying in bed. There was no signage on the door or on the wall outside the resident's room to indicate that the resident was on EBP, and there was no PPE observed in or outside the resident's room.
Interview with the Director of Nursing on November 13, 2024, at 9:47 a.m. confirmed that Resident 9 did not have EBP in place related to the resident's history of ESBL and should have.
A quarterly MDS assessment for Resident 14, dated September 12, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, incontinent of both bowel and bladder, and had diagnosis that included high blood pressure, hemiplegia (weakness on one side of the body), and fibromyalgia (pain in muscles).
A Physician Progress note, dated January 16, 2024, at 6:49 p.m., revealed that Resident 14 was receiving IV antibiotics until January 18, 2024, for diagnosis of Extended Spectrum Beta Lactamase (ESBL) (an infection that makes bacteria resistant to many antibiotics). A urine culture, dated October 8, 2023, confirmed the resident had ESBL.
Observations during the facility tour on November 14, 2024, at 10:55 a.m. revealed that Resident 22 was lying in bed. There was no signage or notification of the resident being on EBP posted at the resident's room, and there was no PPE observed in or around the resident's room.
Interview with the Director of Nursing on September 16, 2024, at 9:23 a.m. confirmed that Resident 22 did not have EBP precautions in place for history of ESBL and should have.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on observations, as well as staff interviews, it was determined that the facility failed to maintain an effective preventative maintenance program for the walk-in-freezer.
Findings include:
Obse...
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Based on observations, as well as staff interviews, it was determined that the facility failed to maintain an effective preventative maintenance program for the walk-in-freezer.
Findings include:
Observations of the walk-in-freezer on November 12, 2024, at 9:26 a.m. and November 13, 2024, at 12:18 p.m. revealed that there was an accumulation of ice on the ceiling extending out from the condenser to the other side of the walk-in-freezer, as well as from the ceiling and extending down the four side walls, and multiple areas on the floor with an accumulation of ice.
Interview with the Dietary Manager on November 13, 2024, at 12:18 p.m. confirmed that there was an accumulation of ice on the ceiling extending out from the condenser to the other side of the walk-in-freezer, as well as from the ceiling and extending the down the four side walls, and multiple areas on the floor with an accumulation of ice.
Interview with the Director of Maintenance on November 13, 2024, at 12:25 p.m. revealed that he has been there six months and does not recall having the walk-in freezer worked on.
Interview with Maintenance Worker 4 on November 13, 2024, at 1:30 p.m. revealed that he does not have a manual for the walk-in freezer and that last summer they had a compressor go bad in the walk-in freezer, and they had a contracted vendor come in and replace the compressor at that time. He indicated that he does not recall having anyone come out to look at the walk-in freezer since then. He indicated that he did ask the service man what could be causing ice buildup and was advised that it could be a bad door seal or that staff are not shutting the door correctly.
28 Pa. Code 201.18(e)(6) Management.
28 Pa. Code 211.6(c) Dietary Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0941
(Tag F0941)
Could have caused harm · This affected 1 resident
Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on effective communication to nursing and other direct care staff for four of ...
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Based on review of facility documents and staff interview, it was determined that the facility failed to provide training on effective communication to nursing and other direct care staff for four of four employee files reviewed (Nurse Aide 5, Nurse Aide 6, Licensed Practical Nurse 7, Registered Nurse 8).
Findings include:
The facility's Facility Assessment (an assessment completed by the facility to thoroughly assess the needs of its resident population and the required resources to provide the care and services the residents need), dated July 17, 2024, revealed that the facility's training program includes an orientation process and ongoing training for all new and existing staff including managers, nursing, and other direct care staff, individuals providing services under contractual arrangement, and volunteers consistent with their expected roles. The content at a minimum included effective communication.
Review of the education record for Nurse Aide 5 revealed a hire date of September 25, 2023. However, there was no documented evidence that she received the facility's education regarding effective communication during the period of September 25, 2023, through September 25, 2024.
Review of the education record for Nurse Aide 6 revealed a hire date of October 7, 2023. However, there was no documented evidence that she received the facility's education regarding effective communication during the period of October 7, 2023, through October 7, 2024.
Review of the education record for Licensed Practical Nurse 7 revealed a hire date of October 11, 2023. However, there was no documented evidence that she received the facility's education regarding effective communication during the period of October 11, 2023, through October 11, 2024.
Review of the education record for Registered Nurse 8 revealed a hire date of September 18, 2023. However, there was no documented evidence that she received the facility's education regarding effective communication during the period of September 18, 2023, through September 18, 2024.
Interview with the Director of Nursing on November 13, 2024, at 12:08 p.m. confirmed that there was no documented evidence that Nurse Aide 5, Nurse Aide 6, Licensed Practical Nurse 7, and Registered Nurse 8 received the facility's education regarding effective communication.
28 Pa Code: 201.14(a) Responsibility of Licensee.
28 Pa Code: 201.18(b)(1) Management.
28 Pa Code: 201.20(a)(c) Staff Development.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Older Adults Protective Services Act, facility policies, information provided by the facility and residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Older Adults Protective Services Act, facility policies, information provided by the facility and residents' clinical records, as well as staff interviews, it was determined that the facility failed to report timely allegations of abuse to the State Survey Agency (Department of Health) and to other state agencies in accordance with state law for three of 30 residents reviewed (Residents 131, 132, 133).
Findings include:
The Older Adults Protective Services Act, 1997-13, Section 701 (a)(1)(2), indicated that it was mandatory to report to the Protective Services agency. An employee or an administrator who has reasonable cause to suspect that a recipient is a victim of abuse shall immediately make an oral report to the agency. If applicable, the agency shall advise the employee or administrator of additional reporting requirements that may pertain under subsection (b). An employee shall notify the administrator immediately following the report to the agency. Within 48 hours of making the oral report, the employee or administrator shall make a written report to the agency. The agency shall notify the administrator that a report of abuse has been made with the agency.
The facility's policy regarding reporting and investigating abuse, neglect, exploitation, or misappropriation, dated December 7, 2023, revealed that if resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, adult protective services, law enforcement officials, the resident's attending physician, and the facility's medical director. Immediately is defined as within two hours of an allegation involving abuse or results in serious bodily injury, or within 24 hours of an allegation that does not involve abuse or results in serious bodily injury.
An admission Minimum Data Set (MDS) assessments (a federally-mandated assessment of a resident's abilities and care needs) for Resident 131, dated August 11, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included a hip fracture. A care plan for the resident, dated August 5, 2024, revealed that the resident required limited to extensive assistance from staff.
An interview statement with Resident 131, undated, revealed that Nurse Aide 1 was like a [NAME] Sergeant, she is nasty. She asked if Nurse Aide 1 could put her leg up because it was falling, and the nurse aide told her do it herself, to lift her foot up. She then asked for the bed control, and the nurse aide told her she could not have it to put her head up and down. The resident said that she always had it. Nurse Aide 1 said if they found out that she gave it to the resident, she would be fired, and she continued to be argumentative. The resident said that she just wanted Nurse Aide 1 out of her room. So, she told Nurse Aide 1 that her son lives right down the road, and she will call him and have him come and take her out of here. She said that she does not want Nurse Aide 1 to take care of her because she was scared of her.
An admission MDS assessment for Resident 132, dated August 2, 2024, revealed that the resident was understood, could understands others, and had diagnoses that included a fractured tibia (the shinbone, the larger of the two bones in the lower leg). A care plan for the resident, dated July 26, 2024, revealed that the resident required limited to extensive assistance from staff.
A statement completed by Nurse Aide 2, dated August 14, 2024, revealed that on August 13, 2024, while responding to Resident 132's light, the resident was telling her how she has not seen her in a while, and she had missed her. The nurse aide told her that she missed her too and asked how she has been. The resident told her how her therapy was helping her and how everyone but one person was nice to her. The nurse aide responded with, Oh no, I'm sorry to hear that. The nurse aide asked her if she wanted to or felt comfortable speaking to her. The resident then told the nurse aide that she had an accident the night prior and Nurse Aide 1 went in and was being rude to her. She said that Nurse Aide 1 was upset with her and stated, I'm done, I'm so f*****g done, and as the nurse aide put her table back beside her bed, Nurse Aide 1 knocked her pop down to the floor and did not pick it back up. Resident 132 had to pick up the soda.
An interview statement with Resident 132 completed by Registered Nurse 3, dated August 14, 2024, revealed that Nurse Aide 1 came in after the resident had an accident. Nurse Aide 1 came in all huffy and puffy because she had to change the resident's bed. Nurse Aide 1 told the resident you have to get out of bed, because I am not going to roll you, so then she knocked over the pop and stated, I'm f*****g done. So, the resident cleaned up the pop and then Nurse Aide 1 came in to care for her roommate and was rude with her roommate and told her that she could not put the head of her bed up, and told her she could be fired if she gave her roommate the remote. As per the resident, this was not the first time. The first time it happened, she let it go. She just figured Nurse Aide 1 was tired or did not feel good.
An admission MDS assessment for Resident 133, dated July 11, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included heart failure (a serious condition that occurs when the heart is unable to pump enough blood and oxygen to the body's organs) and gastrostomy (a surgical procedure that creates an opening in the abdomen that allows a feeding tube to be inserted directly into the stomach). A care plan for the resident, dated September 10, 2024, revealed that the resident required extensive assistance from staff.
A statement completed by Nurse Aide 2, dated August 15, 2024, revealed that that night while helping Resident 133 into bed, the resident's wife had asked the Nurse Aide 2 if it was okay if she helped her husband with his urinal when he has to go. Nurse Aide 2 told her that if she wanted to, she was allowed to help him with his urinal. She then told Nurse Aide 2 that Nurse Aide 1 had come into his room one time as she was helping him with his urinal and snatched it out of her hand, and as she snatched out it out of her hand she was yelling at the resident's wife. The resident's wife also told Nurse Aide 2 that Nurse Aide 1 was always very aggressive with him and whips him back and forth in the bed. Nurse Aide 2 immediately came out of the room and notified the supervisor about the statement/accusations that the resident's wife had said.
Interview with Registered Nurse 3 on November 14, 2024, at 9:35 a.m. revealed that she interviewed Resident 131 on August 14, 2024, after learning that the resident had concerns with Nurse Aide 1 while interviewing Resident 132 after learning that she had care concerns with Nurse Aide 1.
There was no documented evidence until August 20, 2024, that the facility reported the allegations of possible abuse for Residents 131, 132, and 133 to the State Survey Agency (Department of Health), Protective Services agency, and the local police department.
Interview with the Director of Nursing on November 14, 2024, at 10:55 a.m. confirmed that the allegations of possible abuse for Residents 131, 132, and 133 were not reported to the State Survey Agency (Department of Health), Protective Services agency, or the local police department until August 20, 2024. She indicated that she was on vacation when the incidents occurred.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospita...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and resident's representative in writing of the transfer and reason for hospitalization for seven of 30 residents reviewed (Residents 1, 5, 9, 14, 22, 23, 24.). This deficiency was cited as past noncompliance.
Findings include:
A nursing note for Resident 1, dated February 5, 2024, at 1:39 p.m., revealed that Resident 1 was being admitted to the hospital for osteomyelitis. There was no documented evidence that a written notice of Resident 1's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.
Nursing notes for Resident 5, dated September 26, 2024, at 3:06 a.m. and 5:36 a.m., revealed that the resident had a change in mental status with increased confusion, garbled speech, and bad chest pain. The physician was notified and the resident was sent to the hospital for evaluation. She was admitted to the hospital with chest pain, fever, abdominal pain, altered mental status, and leukocytosis (high white blood cell count). There was no documented evidence that a written notice of Resident 5's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.
A nursing note for Resident 9, dated October 11, 2024, at 11:22 p.m., indicated that the resident was very lethargic and her pulse oximetry (measures blood oxygen levels) initially was 78 percent on room air. Oxygen was applied at 4 liters per minute via nasal cannula (a small tube that delivers oxygen through the nasal passages) and her pulse oximetry increased to 91 percent. Her oxygen was turned up to 8 liters per minute via nasal cannula and her pulse oximetry increased to 99 percent. The resident was transferred to the emergency room for an evaluation. There was no documented evidence that a written notice of Resident 9's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.
A nursing note for Resident 14, dated April 6, 2024, revealed that the resident had chest pain that was radiating to the left upper extremity. The CRNP was notified and ordered the resident to be transferred to the local emergency room. There was no documented evidence that a written notice of Resident 14's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.
A nursing note for Resident 22, dated October 21, 2024, at 2:33 p.m., revealed that the resident had fallen in the bathroom. After the fall, the resident rolled to her right side because she was having pain to her left hip and wrist. The resident's left wrist was swollen and very painful to touch and the resident was unable to straighten her leg. The CRNP was notified and ordered the resident to be transferred to the local emergency room. A nursing note, dated October 21, 2024, at 11:59 p.m., revealed that Resident 22 was admitted with a left hip fracture and a left wrist fracture. There was no documented evidence that a written notice of Resident 22's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.
Nursing notes for Resident 23, dated October 1, 2024, at 9:38 a.m. and 12:37 p.m., revealed that the resident had severe left knee pain that was red/purple in color, was hot to tough, and had drainage from the incision site. She was transferred to the hospital and admitted with cellulitis (bacterial skin infection). There was no documented evidence that a written notice of Resident 23's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.
A nursing note for Resident 24, dated July 18, 2024, at 3:04 p.m., revealed that the resident had gastrointestinal pain with diarrhea, pain, and intermittent fever. An order was obtained to transfer the resident to the local emergency room. A nursing note, dated July 18, 2024, at 9:32 p.m., revealed that Resident 24 was being admitted with colitis and urinary tract infection. There was no documented evidence that a written notice of Resident 24's transfer to the hospital was provided to the resident's representative and state ombudsman regarding the reason for transfer.
Interview with the Director of Nursing on November 13, 2024, at 11:18 p.m. confirmed that the facility did not provide a written notice to the above residents and/or their representative when the residents were transferred to the hospital. She also confirmed that the facility did not notify the state ombudsman of transfers to the hospital. The Director of Nursing indicated that they had identified the issue of not providing written notices of the transfers to the hospital on October 25, 2024.
Following the identification on October 25, 2024, that they were not providing the written notices to the resident and/or the resident's representative and state ombudsman when the resident was transferred to the hospital, the facility's corrective actions included:
Education was provided to staff regarding the required written notice that was to be given to the resident and/or the resident's representative when the resident was transferred to the hospital. Education was provided to staff regarding the required notice to the state ombudsman when the resident was transferred to the hospital.
Audits were started on all residents that were transferred to the hospital.
The results of these audits will be brought to the Quality Assurance Performance Improvement committee for further analysis and corrective actions if necessary.
Review of the facility's corrective actions and interviews completed with staff regarding their re-education revealed that they were in compliance with F623 on November 11, 2024.
28 Pa. Code 201.25 Discharge Policy.
28 Pa. Code 201.29(f)(g) Resident Rights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to administer medications and obtain weights as ordered by the physician for two of 30 residents revie...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to administer medications and obtain weights as ordered by the physician for two of 30 residents reviewed (Residents 5, 17).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated October 9, 2024, revealed that the resident was moderately cognitively intact, required assistance from staff for daily care needs and had diagnoses that included heart failure.
Physician's orders for Resident 5, dated October 7, 2024, included an order for the resident to receive 5 milligrams (mg) of Midodrine (a medication that treats low blood pressure) three times a day for hypotension (low blood pressure) and was to be held if the systolic blood pressure (the top number in a blood pressure reading) was greater than 130 millimeters of mercury (mmHg).
A review of Resident 5's Medication Administration Record (MAR) for October and November 2024 revealed that staff administered the 5 mg of Midodrine when the resident's blood pressure was 138/76 mmHg at 8:00 a.m. on October 8; 135/76 mmHg at 8:00 a.m. on October 14; 132/82 mmHg at 2:00 p.m. on October 14; 140/90 mmHg at 2:00 p.m. on October 30; 134/80 mmHg at 8:00 p.m. on October 30; 138/78 mmHg at 8:00 a.m. on November 1; 132/78 mmHg at 2:00 p.m. on November 1; 142/68 mmHg at 8:00 a.m. on November 2; 144/76 mmHg at 2:00 p.m. on November 2; 138/74 mmHg at 2:00 p.m. on November 5; 133/74 mmHg at 2:00 p.m. on November 11; and 138/71 mmHg at 8:00 p.m. on November 8, 2024.
Interview with the Director of Nursing on November 14, 2024, at 10:50 a.m. confirmed that Resident 5 received the Midodrine on the above dates and that staff should have held the medication as ordered.
A quarterly MDS assessment for Resident 17, dated October 10, 2024, indicated that the resident was cognitively impaired, required assistance with daily care needs, was on a diuretic medication, and had diagnoses that included chronic kidney disease Stage 3 (moderate to severe loss of kidney function) and congestive heart failure (the heart cannot pump blood as well as it should, causing weight gain due to fluid build up in the lungs and lower legs).
A physician's note for Resident 17, dated April 8, 2024, at 8:56 p.m., indicated that the resident had increased left upper extremity edema and bilateral lower extremity edema.
Physician's orders for Resident 17, dated April 17, 2024, included orders to increase the Lasix to 60 milligrams daily, obtain bloodwork in a week, and to weigh the resident weekly on Thursdays.
A review of Resident 17's MAR for May, June, August, September, October and November 2024 revealed that the resident was not weighed as ordered on May 2, June 13, June 20, June 27, August 8, August 29, September 5, October 10, October 17, October 31, and November 7, 2024, and no documentation in the clinical record to indicate that the weights were attempted and refused by the resident on those days.
Interview with the Director of Nursing on November 13, 2024, at 1:33 p.m. confirmed that Resident 17's weights were not obtained as ordered on the above-mentioned dates.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potentia...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 30 residents reviewed (Residents 12, 22, 26).
Findings include:
The facility's policy regarding the administration of oral medications, dated December 7, 2023, indicated that the nurse was to document all medications administered to each resident on the resident's medication administration record (MAR).
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 12, dated September 19, 2024, indicated that the resident was understood and could understand others, required assistance with daily care needs, received antianxiety and opioid medications, was receiving oxygen therapy and hospice services, and had a diagnosis of congestive heart (the heart cannot pump blood well enough to meet the body's needs).
Physician's orders for Resident 12, dated September 11, 2024, included an order for the resident to receive 0.5 milligrams (mg) of Ativan (Lorazepam - a controlled medication used to treat anxiety) every four hours as needed for anxiety/restlessness for 14 days (end date of September 25, 2024).
A review of Resident 12's controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug)
for September 2024 revealed that a 0.5 mg tablet of Lorazepam was signed out for the resident on September 13, 2024, at 8:00 p.m. and September 23, 2024, at 10:30 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out 0.5 mg doses of Lorazepam were administered to the resident on these dates and times.
A review of Resident 12's controlled drug record for October 2024 revealed that a 0.5 mg tablet of Lorazepam was signed out for the resident on October 26, 2024, at 12:00 a.m. and on October 27, 2024, at 10:30 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence of an active physician's order for Lorazepam or that the signed-out doses were administered to the resident on these dates and times.
Physician's orders for Resident 12, dated April 11, 2024, included an order for the resident to receive 50 mg of Tramadol (narcotic pain reliever) every six hours as needed for moderate to severe pain.
A review of Resident 12's controlled drug record for August, September, and November 2024 revealed that a 50 mg tablet of Tramadol was signed out for the resident on August 10, 2024, at 6:30 a.m.; August 17, 2024, at 4:58 p.m. and 10:58 p.m.; August 23, 2024, at 7:35 a.m.; August 24, 2024, at 9:05 a.m.; September 2, 2024, at 1:37 p.m.; September 5, 2024, at 8:00 p.m.; September 8, 2024, at 8:10 a.m.; September 23, 2024, at 8:30 p.m.; September 24, 2024, at 12:17 a.m.; and on November 5, 2024 at 6:24 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out 50 mg tablets of Tramadol were administered to the resident on these dates.
Interview with the Director of Nursing on November 13, 2024, at 2:35 p.m. confirmed that there was no documented evidence that staff administered the controlled drugs to Resident 12 on the above-mentioned dates and times.
An admission MDS assessment for Resident 22 dated October 4, 2024, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included anemia, high blood pressure, and chronic obstructive pulmonary disease.
Physician's orders for Resident 22, dated September 27, 2024, included an order for the resident to receive 0.25 milliliters (ml) of Morphine Sulfate (controlled pain medication) every two hours as needed for pain.
A review of Resident 22's controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for October and November 2024 revealed that 0.25 ml of Morphine was signed out for the resident on October 8, 2024, at 2:53 a.m.; October 31, 2024, at 1:00 a.m.; November 4 2024, at 12:23 a.m.; November 7, 2024, at 2:25 a.m.; November 13, 2024, at 3:55 a.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out 0.25 ml doses of Morphine were administered to the resident on these dates.
An interview with the Director of Nursing on November 13, 2024, at 12:08 p.m. confirmed that there was no documented evidence that staff administered the controlled drugs to Resident 22 on the dates mentioned above.
An admission MDS assessment for Resident 26, dated October 8, 2024, revealed that the resident was cognitively intact, had pain, received routine and as needed pain medications, and received an opioid (narcotic pain medication).
Physician's orders for Resident 26, dated October 2, 2024, included an order for the resident to receive 5 mg of oxycodone (narcotic pain medication) every six hours as needed.
The resident's controlled drug record for October and November 2024 indicated that one dose of oxycodone was signed-out for administration to the resident on October 2 at 10:30 p.m., October 26 at 4:00 a.m., October 28 at 8:42 a.m., October 30 at 9:00 p.m., November 2 at 10:15 a.m., and November 8, 2024, at 9:00 p.m. However, the resident's clinical record, including the Medication Administration Records (MAR's) and nursing notes, contained no documented evidence that the signed-out doses of oxycodone were actually administered to the resident on these dates and times.
Interview with the Director of Nursing on November 13, 2024, at 1:58 p.m. confirmed that there was no documented evidence that staff administered the signed-out doses of oxycodone to Resident 26 on the above dates and times.
28 Pa. Code 211.9(h) Pharmacy Services.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Jul 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure an assessment was completed by a professi...
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Based on review of Pennsylvania's Nursing Practice Act and clinical records, as well as staff interviews, it was determined that the facility failed to ensure an assessment was completed by a professional (registered) nurse for a change in condition for one of five residents reviewed (Resident 1).
Findings include:
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicated that the registered nurse was to collect complete and ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain and restore the well-being of individuals.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated April 20, 2024, revealed that the resident was cognitively intact and required assistance from staff for daily care needs.
A nursing note for Resident 1, dated April 26, 2024, revealed that the resident was short of breath, breathing 44 times per minute with heavy diaphragmatic breathing (using stomach muscles to breath), skin was dusky color, and nail beds and lips were blue.
There was no documented evidence that Resident 1 was assessed by a registered nurse during or after his respiratory distress.
A nursing note for Resident 1, dated April 29, 2024, revealed that the resident's oxygen level was 72 percent (hypoxia - low blood oxygen) and that he was found without his oxygen on.
There was no documented evidence that Resident 1 was assessed by a registered nurse during or after his hypoxic episode.
A nursing note, dated May 1, 2024, revealed that the resident had shortness of breath, oxygen levels in the low in the 70's, and that he was being transferred to the emergency room where he was admitted with pneumonia and sepsis.
Interview with the Director of Nursing on July 30, 2024, confirmed that there was no documented evidence that a registered nurse assessed Resident 1 after he had respiratory distress and hypoxia, and there should have been a registered nurse assessment.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
Dec 2023
12 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a professional licensure check prior to hire for one licensed pract...
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Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a professional licensure check prior to hire for one licensed practical nurse reviewed (Licensed Practical Nurse 1) and failed to complete a nurse aide registry check for one of three nurse aides reviewed (Nurse Aide 2).
Findings include:
The facility's abuse policy, dated December 7, 2023, indicated that the facility will conduct employee background checks and will not knowingly employ any individual who has had a finding entered into the nurse aide registry concerning abuse or neglect, or any individual that has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse or neglect.
Review of the personnel file for Licensed Practical Nurse 1 revealed that she was hired on October 11, 2023, and the Pennsylvania Professional Licensure check was not conducted until December 19, 2023, two months after she was hired.
Review of the personnel file for Nurse Aide 2 revealed that she was hired on October 9, 2023, and the Pennsylvania Nurse Aide Registry check was not verified until December 19, 2023, more than two months after she was hired.
Interview with the Registered Nurse Assessment Coordinator on December 20, 2023, at 9:31 a.m. confirmed that there was no documented evidence that a professional licensure check was completed for Licensed Practical Nurse 1 or that a nurse aide registry check was completed for Nurse Aide 2 prior to their dates of hire.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the resident and/or responsible party was notified about the facility's bed-hold pol...
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Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that the resident and/or responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for one of 19 residents reviewed (Resident 3).
Findings include:
A nurse's note for Resident 3, dated August 16, 2023, at 4:01 p.m. revealed that the resident developed left facial drop and slurred speech and was transferred to the hospital. A nurse's note, dated August 17, 2023, at 6:41 a.m., revealed that the resident was admitted to the hospital.
A nurse's note for Resident 3, dated September 24, 2023, at 8:32 a.m. revealed that the resident had a change in condition and had requested to be transferred to the hospital. A nurse's note, dated September 25, 2023, at 10:08 a.m., revealed that the resident was admitted to the hospital.
There was no documented evidence that Resident 3 and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfers to the hospital.
Interview with the Registered Nurse Assessment Coordinator on December 20, 2023, at 11:37 a.m. confirmed there was no documented evidence that a bed-hold notice was issued to Resident 3 or her responsible party at the time of the transfers to the hospital.
28 Pa. Code 201.29(a) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for four of 19 residents revie...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to develop care plans for individualized resident care needs for four of 19 residents reviewed (Residents 6, 17, 18, 22).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated October 10, 2023, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, was continent of bowel and urine, and had a significant weight gain. A review of Resident 6's clinical record revealed that the resident had a history of urinary tract infections.
A physician's order for Resident 6, dated December 15, 2023, included an order for the resident to receive Cephalexin (an antibiotic) two times a day for a urinary tract infection until December 22, 2023.
There was no documented evidence that a care plan was developed to address Resident 6's urinary tract infection with antibiotic treatment.
An interview with the Registered Nurse Assessment Coordinator (RNAC) on December 20, 2023, at 11:22 a.m. confirmed there was no care plan in place to address Resident 6's urinary tract infection with antibiotic treatment and there should have been.
An admission MDS assessment for Resident 17, dated November 16, 2023, indicated that the resident was cognitively intact, required assistance from staff with her daily care needs, was dependent on staff for transfers with use a mechanical lift, was incontinent of bowel and urine, had a Stage 2 pressure area (a shallow open wound), moisture-associated skin damage (inflammation of the skin caused by exposure to moisture), and had a diagnosis of morbid obesity.
Physician's orders for Resident 17, dated November 12, 2023, included an order to cleanse bilateral posterior thighs with soap and water, pat dry, and apply Zinc cream topically every shift and as needed for incontinence. A physician's order, dated December 6, 2023, included an order to cleanse bilateral thigh and buttocks with normal saline cleanser, apply collagen, and cover with border gauze every shift daily and as needed. A physician's order, dated December 6, 2023, included an order to cleanse the open area to right posterior upper leg with wound cleanser, apply collagen, and secure with border gauze daily and as needed.
There was no documented evidence that a care plan was developed to address Resident 17's skin impairments.
Interview with the RNAC on December 19, 2023, at 1:55 p.m. confirmed that there was no care plan developed to address Resident 17's skin impairments and there should have been.
A quarterly MDS assessment for Resident 18, dated September 4, 2023, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, and had a significant weight gain. Resident 18's diagnoses included end-stage renal disease (kidneys no longer work as they should).
Physician's orders for Resident 18, dated December 6, 2023, included an order for the resident to receive dialysis (treatment to remove excess fluids and waste for people whose kidneys are failing) at 9:30 a.m. on Tuesdays, Thursdays and Saturdays.
There was no documented evidence that a care plan was developed to address Resident 18's care related to renal disease and the need for dialysis.
Interview with the RNAC on December 19, 2023, at 2:19 p.m. confirmed that there was no care plan developed to address Resident 18's renal disease and dialysis and there should have been.
An admission MDS assessment for Resident 22, dated September 22, 2023, revealed that the resident was cognitively intact, required limited assistance with personal hygiene needs, and had diagnoses that included requiring surgical care after a surgery, anxiety and obesity.
Nursing notes for Resident 22, dated October 15, 2023; November 8 and 24, 2023; and December 1 and 16, 2023, revealed that the resident had refused the showers offered to her.
Interview with the Social Worker on December 18, 2023, at 10:50 a.m. revealed that the resident sometimes hides her clothes and refuses to let staff wash them.
There was no documented evidence that a care plan was developed and implemented to address Resident 22's refusal of care.
Interview with the Registered Nurse Assessment Coordinator on December 20, 2023, at 1:19 p.m. confirmed that a care plan for Resident 22's refusal of care was not developed and implemented and should have been.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in ...
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Based on review of clinical records and observations, as well as resident and staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in care needs for four of 19 residents reviewed (Residents 6, 9, 22, 40).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated October 10, 2023, indicated that the resident was cognitively intact, required assistance from staff for her daily care needs, was continent of bowel and urine, and had a significant weight gain.
Observations of Resident 6 on December 18, 2023, at 11:15 a.m. revealed the resident was lying in bed. The resident stated she had not been out of bed for the last three to four weeks because staff had stated that the mechanical lift would not support her weight.
Interview with the Registered Nurse Assessment Coordinator (RNAC) on December 19, 2023, at 2:00 p.m. revealed that Resident 6 was not able to get out of bed due to her weight exceeding the maximum weight limit of 450 pounds for the mechanical lift. Resident 6's weight on November 22, 2023, was 456 pounds. The RNAC stated that they purchased a transfer device so the resident could be transferred in case of an emergency and looked at purchasing a mechanical lift with a maximum weight limit of 600 pounds. Resident 6's care plan, last revised on November 10, 2023, revealed that she is transferred with a hoyer lift (a mechanical lift) with assist of two staff.
Interview with the RNAC on December 19, 2023, at 2:21 p.m. confirmed that Resident 6's care plan was not revised to reflect her change in transfer status and it should have been.
A quarterly MDS assessment for Resident 9, dated August 15, 2023, revealed that the resident was cognitively impaired, required extensive assist to total dependence with care needs, had a diagnosis of pneumonia (infection in the lungs), and had a feeding tube (a mechanical device that delivers food, fluids and medications to a person who is unable to eat or drink). A care plan for Resident 9, last revised on October 13, 2023, instructed to elevate the head of the bed 30 to 45 degrees during feeding administration.
Physician's order for Resident 9, dated November 22, 2023, indicated to elevate the head of the bed at least 60 to 75 degrees during feeding and for one hour after. Physician's orders, dated October 19, 2023, indicated to check for residual every shift and hold feeding for one hour if above 90 cc.
Interview with the RNAC on December 20, 2023, at 1:28 p.m. confirmed that Resident 9's care plan was not revised to reflect changes in positioning during tube feeding and checking for a residual and that it should have been.
An admission MDS assessment for Resident 22, dated September 22, 2023, revealed the resident was cognitively intact, required limited assistance with personal hygiene needs, and had diagnoses that included requiring surgical care after a surgery, anxiety and obesity.
A care plan for Resident 22, dated September 18, 2023, indicated that the resident has a surgical wound site from a hiatal hernia (when the upper part of the stomach bulges through the large muscle that separates the abdomen and the chest) repair and that treatments were to be provided per physician's orders.
Nurse's note for Resident 22, dated October 10, 2023, revealed that staff was to discontinue treatment to her abdominal incision because it had healed.
Interview with the Registered Nurse Assessment Coordinator on December 20, 2023, at 1:19 p.m. confirmed that Resident 22's care plan should have been revised when her surgical incision had healed but it was not.
Review of admission records for Resident 40, dated December 5, 2023, revealed that the resident had diagnosis that included spinal stenosis (narrowing of the spinal column) and diabetes and had a Stage 4 (tissue loss with exposed bone, tendon, or muscle) Sacrococcygeal (area that includes the base of the spine and the tailbone) pressure ulcer (injuries to skin resulting from prolonged pressure).
Observations of Resident 40 on December 18, 2023, at 11:20 a.m. revealed that the resident's bed was equipped with an air mattress.
A care plan for Resident 40, dated December 6, 2023, revealed that the resident had skin breakdown that included a Stage 4 Sacrococcygeal pressure ulcer. There was no documented evidence in the resident's care plan to indicate that she was to have an air mattress.
Interview with the Registered Nurse Assessment Coordinator on December 20, 2023, at 11:37 a.m. revealed that it was determined that an air mattress would benefit Resident 40 and was attached to her bed; however, the resident's care plan was never revised to include the air mattress.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to complete weekly wound assessments for one of 19 residents reviewed (Resident 8) and ...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to complete weekly wound assessments for one of 19 residents reviewed (Resident 8) and failed to notify the physician about a medication allergy for one of 19 residents reviewed (Resident 40).
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated November 5, 2023, revealed that the resident was cognitively intact, required supervision with care needs, was at risk for developing pressure ulcers, had venous ulcers (ulcers caused by poor blood flow in leg veins), and had a diagnosis of peripheral vascular disease (a disease causing poor blood circulation to lower limbs). A care plan for Resident 8, revised on November 30, 2023, revealed that the resident had skin breakdown related to venous stasis ulcers of right ankle, right medial foot, right dorsal foot, and left dorsal foot. Interventions included to report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, and to notify physician as needed.
Physician's orders for Resident 8, dated December 5, 2023, included an order to cleanse her right medial foot and ankle with wound cleanser, apply 500 milligrams (mg) of crushed Flagyl (an antibiotic), cover with silver alginate (a wound dressing that contain silver ions, which have antimicrobial properties and can help prevent infections) abdominal dressing and rolled gauze daily and as needed.
Physician's orders for Resident 8, dated December 19, 2023, included orders to cleanse her right dorsal foot, ankle and leg with wound cleanser; apply oil emulsion cover (non-adherent wound product); cover with silver alginate; wrap with rolled gauze daily and as needed; and to cleanse her left foot with soap and water daily, pat dry, apply gauze and Kling, and wrap daily and as needed.
Review of Resident 8's clinical record revealed no documented evidence of weekly wound assessments by the facility's medical staff between May 25, 2023, and August 2, 2023.
Interview with Licensed Practical Nurse 3 on December 20, 2023, at 12:42 p.m. confirmed that Resident 8's wounds were not assessed weekly between May 25, 2023, and August 2, 2023.
Interview with the Nursing Home Administrator on December 20, 2023, at 3:05 p.m. confirmed that there was no documented evidence that Resident 8's wounds were assessed weekly from May 25, 2023, until August 2, 2023, and they should have been.
Review of admission records for Resident 40, dated December 5, 2023, revealed that the resident had diagnoses that included spinal stenosis (narrowing of the spinal column) diabetes and a Stage 4 (tissue loss with exposed bone, tendon, or muscle) Sacrococcygeal (area that includes the base of the spine and the tailbone) pressure ulcer (injuries to skin resulting from prolonged pressure).
Physician's orders for Resident 40, dated December 6, 2023, at 2:15 p.m. included an order for the resident to receive two 325 milligrams (mg) tablets of Tylenol every four hours as needed for pain.
A nurse's note for Resident 40, dated December 5, 2023, at 9:59 p.m. revealed that the resident was admitted to the facility from a hospital, had periods of confusion, had an allergy to acetaminophen (generic form of Tylenol), and that the Tylenol protocol was not to be given. There was no documented evidence in the clinical record to indicate that the physician was made aware of Resident 40's Tylenol allergy.
Review of Resident 40's Medication Administration Record (MAR) for December 2023 revealed that the resident received two 325 mg tablets of Tylenol for pain on December 9 at 7:17 p.m., December 14 at 9:57 a.m., December 17 at 1:27 a.m., and December 19 at 8:15 a.m.
Interview with the Registered Nurse Assessment Coordinator on December 20, 2023, at 11:37 a.m. confirmed that there was no documented evidence that the physician was made aware of Resident 40's allergy to Tylenol when it was ordered.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on review of clinical records and facility assessment reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for three of 19 residents re...
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Based on review of clinical records and facility assessment reports, as well as staff interviews, it was determined that the facility failed to complete safety assessments for three of 19 residents reviewed (Residents 9, 17, 40) who used an air mattress.
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated August 15, 2023, revealed that the resident was cognitively impaired, required extensive assist to total dependence with care needs, and was at risk for developing pressure ulcers.
Observations on December 18, 2023, at 10:35 a.m. revealed that Resident 9 was lying in bed and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed.
Interview with the Registered Nurse Assessment Coordinator (RNAC) on December 20, 2023, at 11:21 a.m. confirmed that there was no assessment for potential safety hazards prior to the air mattress being placed on the Resident 9's bed and there should have been.
An admission MDS assessment for Resident 17, dated November 16, 2023, indicated that the resident was cognitively intact, required assistance from staff with her daily care needs, was dependent on staff for transfers with use of a mechanical lift, was incontinent of bowel and urine, had a Stage 2 pressure area (a shallow open wound), moisture-associated skin damage (inflammation of the skin caused by exposure to moisture), and had a diagnosis of morbid obesity. Physician's orders, dated November 16, 2023, included an order for the resident's bed to be equipped with an air mattress.
Observations on December 18, 2023, at 11:00 a.m. revealed that Resident 17 was lying in bed and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed.
Interview with the Registered Nurse Assessment Coordinator (RNAC) on December 19, 2023, at 2:27 p.m. confirmed that there was no assessment for potential safety hazards prior to the air mattress being placed on the Resident 17's bed and there should have been.
Review of admission records for Resident 40, dated December 5, 2023, revealed the resident had diagnoses that included spinal stenosis (narrowing of the spinal column), diabetes, and a Stage 4 (tissue loss with exposed bone, tendon, or muscle) Sacrococcygeal (area that includes the base of the spine and the tailbone) pressure ulcer (injuries to skin resulting from prolonged pressure).
Observations of Resident 40 on December 18, 2023, at 11:20 a.m. revealed the resident's bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed.
Interview with the registered Nurse Assessment Coordinator on December 20, 2023, 11:37 a.m. confirmed there was no assessment for potential safety hazards prior to an air mattress being placed on Resident 40's bed.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(e)(1) Management.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potentia...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain accountability for controlled medications (drugs with the potential to be abused) for three of 19 residents reviewed (Resident 11, 15, 17).
Findings include:
The facility's policy regarding the administration of oral medications, dated December 7, 2023, indicated that the nurse will document on the Medication Administration Record (MAR) with their initials, at the appropriate date and time for the medication administered, after witnessing the ingestion of the medication.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated November 16, 2023, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included arthritis, high blood pressure, and chronic pain syndrome.
Physician's orders for Resident 11, dated November 10, 2023, included an order for the resident to receive 10-325 milligrams (mg) of Hydrocodone (a controlled pain medication) every eight hours as needed for moderate to severe pain.
A review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 11 for November 2023 indicated that a dose of 10-325 mg of Hydrocodone was signed out on November 21, 2023, and on November 27, 2023. However, the resident's clinical record contained no documented evidence that the signed-out tablet of Hydrocodone was administered to the resident on the dates that were mentioned.
A quarterly MDS assessment for Resident 15, dated November 10, 2023, revealed that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included high blood pressure and fibromyalgia (disorder that affects muscle causing pain).
Physician's orders for Resident 15, dated July 3, 2023, included an order for the resident to receive 5-325 milligrams (mg) of Hydrocodone (a controlled pain medication) every six hours as needed for moderate to severe pain.
A review of the controlled drug record for Resident 15, for October, November and December 2023 indicated that one 5-325 mg tablet of Hydrocodone was signed out on October 27, October 30, November 19, and December 2, 2023, for administration to the resident. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out tablet of Hydrocodone was administered to the resident on the dates that were mentioned.
An interview with the Registered Nurse Assessment Coordinator on December 20, 2023, at 11:21 a.m. confirmed that there was no documented evidence that staff administered the controlled drugs to Residents 11 and 15 on the dates mentioned above.
An admission MDS assessment for Resident 17, dated November 16, 2023, indicated that the resident was cognitively intact, required assistance from staff with her daily care needs, had a Stage 2 pressure area (a shallow open wound), occasional pain, and a diagnosis of anxiety.
Physician's orders for Resident 17, dated December 4, 2023, included an order for the resident to receive 50 milligrams (mg) of Tramadol HCL (a controlled pain medication) every eight hours as needed for severe pain. Physician's orders for Resident 17, dated November 29, 2023, included an order for the resident to receive 0.5 mg of Lorazepam (a controlled anxiety medication) every eight hours as needed for anxiety or restlessness.
A review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 17, dated November 15, 2023, and December 4, 2023, indicated that one 50 mg tablet of Tramadol HCL was signed-out for administration to the resident. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out tablet of Tramadol HCL was administered to the resident on these dates.
A review of the controlled drug record for Resident 17 revealed that one 0.5 mg tablet of Lorazepam was signed out on December 5, 2023, for administration to the resident. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out tablet of Lorazepam was administered to the resident on this date.
An interview with the Regional Director on December 20, 2023, at 2:15 p.m. confirmed that there was no documented evidence that staff administered the Lorazepam to Resident 17 on the date mentioned above.
28 Pa. Code 211.9(h) Pharmacy services.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on review of policies, clinical records, and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to properly secure and store me...
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Based on review of policies, clinical records, and manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to properly secure and store medications in the medication carts and failed to properly label medications in the medication room.
Findings include:
The facility's policy regarding administering medications, dated December 7, 2023, indicated that the medication cart was to be kept closed and locked when out of site of the medication nurse, no medications were to be kept on top of the cart, and when opening a multi-dose container, the date opened was to be recorded on the container.
Observations of a medication pass on December 19, 2023, at 7:40 a.m. revealed that Licensed Practical Nurse 4 left a card of Naproxen 500 milligram (mg) tablets and a card of Allopurinol 100 mg tablets on top of the medication cart unsupervised while he entered a resident's room to administer medication. Interview with Licensed Practical Nurse 4 at that time confirmed that he should not have left the medication on top of the cart unsupervised.
Manufacturer's Instructions for Tubersol, dated November 1, 2021, indicated that a multi-dose vial of Tubersol solution should be discarded 30 days after it is opened.
Observations of the facility's medication room on December 20, 2023, at 11:13 a.m. revealed that the door to the medication room was open, unlocked, and unsupervised. Observation of the medication room refrigerator at that time revealed one opened and undated bottle of Tubersol Tuberculin injection for Mantoux TB skin test (to test for tuberculosis).
Interview with Registered Nurse 5 on December 20, 2023, at 11:13 a.m. confirmed that the bottle of Tubersol was not dated when it was opened and that it should have been, and the door to the medication room should have been closed and locked.
Interview with the Nursing Home Administrator on December 19, 2023, at 9:26 a.m. confirmed that medications should not have been left unsupervised on top of the medication cart and should have been secured in the medication cart when the nurse walked away from the cart.
Interview with the Registered Nurse Assessment Coordinator on December 20, 2023, at 3:56 p.m. confirmed that the door to the medication room was to be kept shut and locked when not in use and that the Tubersol should have been dated when opened.
28 Pa. Code 211.9(a)(1) Pharmacy services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for f...
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Based on review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards for food service safety by not dating opened food items and not storing food under sanitary conditions.
Findings include:
The facility's policy regarding food storage, dated December 7, 2023, revealed that leftover food was to be stored in covered containers or wrapped carefully and securely. Each item was to be clearly labeled and dated before being refrigerated or frozen. All stock must be rotated with each new order received; new items were to be placed behind the supply in stock so that the oldest stock is always used first.
Observations in the kitchen refrigerator on December 18, 2023, at 9:43 a.m. revealed an opened and undated package of lunch meat. Observations in the kitchen's walk-in refrigerator at 9:46 a.m. revealed a block of opened swiss cheese that was dated November 24, 2023, and three unopened containers of orange juice with a best by date of October 19, 2023.
Interview with the Dietary Manager at the time of observations confirmed that the opened package of lunch meat should have been dated when opened, the block of cheese should have been discarded, and the orange juice was outdated and should have been discarded.
28 Pa. Code 211.6(f) Dietary services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained ...
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Based on review of hospice contracts and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the designated interdisciplinary team member obtained the required information from the contracted hospice provider for one of one hospice residents reviewed (Resident 19).
Findings include:
An agreement between the facility and a hospice provider (provider of end-of-life services) indicated that the hospice provider would provide information to the facility to facilitate coordination of care that included the most recent hospice plan of care specific to each patient and a hospice benefit of elections form (a form signed to indicate that the individual waives all rights to traditional Medicare Part A payments for treatment related to the terminal illness).
Physician's orders for Resident 19, dated August 31, 2023, revealed that the resident was to receive hospice services from the facility's contracted hospice provider. As of December 20, 2023, there was no documented evidence in the resident's clinical record, or in the hospice provider's clinical record, that the facility obtained the hospice benefit of elections form from the hospice provider.
Interview with the Registered Nurse Assessment Coordinator on December 20, 2023, at 11:30 a.m. confirmed that there was no evidence that the election of benefits was on Resident 19's hospice chart.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected 1 resident
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of corrections for a State Survey and Certification (Department of Health) survey ending February 1, 2023; complaint investigation surveys ending June 13, 2023, and September 20, 2023; and revisit surveys ending July 24, 2023, and October 30, 2023, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending December 20, 2023, identified repeated deficiencies related to care plan timing and revision, the failure to provide quality of care, safe environment free from accident hazards, storage and labeling of medications, and infection control.
The facility's plan of correction for a deficiency regarding care plan timing and revision, cited during the surveys ending June 13, 2023; July 24, 2023; September 20, 2023; and October 20, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding care plan timing and revision.
The facility's plan of correction for a deficiency regarding quality of care, cited during the surveys ending February 1, 2023, and September 20, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.
The facility's plans of correction for deficiencies regarding a safe environment that is free of accident hazards, cited during the surveys ending September 20, 2023, and October 30, 2023, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding a safe environment that is free of accident hazards.
The facility's plans of correction for deficiencies regarding storage and labeling of medications, cited during the survey ending February 1, 2023, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding storage and labeling of medications.
The facility's plans of correction for deficiencies regarding infection control, cited during the surveys ending September 20, 2023, and October 30, 2023, revealed that the facility developed plans of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F880, revealed that the facility's QAPI committee failed to maintain compliance with the regulation regarding infection control.
Refer to F657, F684, F689, F761, F880.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread...
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Based on review of facility policies and clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related to an Extended Spectrum Beta-Lactamase (ESBL- Beta-lactamases are enzymes produced by some bacteria that may make them resistant to some antibiotics) infection in the urine for one of 19 residents reviewed (Resident 15).
Findings include:
The facility's Infection Prevention and Control policy, dated December 7, 2023, revealed that contact precautions are intended to prevent the transmission of infectious agents which are spread through direct or indirect contact with the patient or the patient's environment. Contact precautions also apply where the presence of excessive wound drainage, urine or fecal incontinence, or other discharges from the body suggest an increased potential for environmental contamination and risk of transmission. Enhanced barrier protections are intended to prevent transmission of multi-drug resistant organisms (MDRO's-bacteria that have become resistant to certain antibiotics) via contaminated hands and clothing of healthcare workers to high-risk residents.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated November 10, 2023, revealed that the resident was cognitively intact, required assistance with staff for daily care needs, was incontinent of urine, and had diagnoses that included high blood pressure and fibromyalgia (a disorder that affects muscles, causing pain).
A nursing note for Resident 15, dated December 6, 2023, at 4:56 p.m. revealed that the resident was at the hospital and was diagnosed with a urinary tract infection containing ESBL and Escherichia coli.
Physician's orders for Resident 15, dated December 9, 2023, included an order for the resident to receive 1 gram of Ertapenem Sodium Intravenous (an antibiotic used to treat multi-drug resistance and ESBL) daily.
A review of the clinical record, including physician orders, nurse's notes and care plans, for Resident 15, dated December 2023, revealed that as of December 20, 2023, there was no documented evidence that transmission-based precautions were ordered or implemented related to Resident 15's ESBL infection.
Observations of Resident 15 on December 18, 19, and 20, 2023, revealed that there was no signage to alert staff and visitors of contact precautions for the resident and no observations that contact precautions were being implemented when providing care to the resident.
Interview with the Director of Nursing on December 20, 2023, at 3:01 p.m. confirmed that contact isolation precautions were never initiated after Resident 15's return from the hospital with a positive ESBL infection and should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Sept 2023
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician was notified about medications not being available for administration on ...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the physician was notified about medications not being available for administration on multiple days for one of 10 residents reviewed (Resident 6).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 24, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance from staff for daily care needs, was incontinent of bladder, and had diagnoses that included a urinary tract infection within the past 30 days and end-stage renal (kidney) disease.
Physician's orders for Resident 6, dated September 14, 2023, included an order for the resident to receive 500 milligrams (mg) of cefuroxime axetil (antibiotic) twice a day for five days for a urinary tract infection.
The Medication Administration Record (MAR) for Resident 6, dated September 2023, indicated that the resident did not receive cefuroxime axetil on September 14, 2023, at 8:00 a.m. and 8:00 p.m. and September 18, 2023, at 8:00 a.m. due to not being available from the pharmacy.
There was no documented evidence that the physician was notified that cefuroxime axetil was not available from the pharmacy and that the cefuroxime axetil was not administered to Resident 6 twice a day for five days.
Physician's order for Resident 6, dated September 14, 2023, included an order for the resident to receive 800 mg of Sevelamer HCl (used to control high blood levels of phosphorus in people with chronic kidney disease) with meals (8:00 a.m., 12:00 p.m., 5:00 p.m.) for end-stage renal failure.
The MAR for Resident 6, dated September 2023, indicated that the resident did not receive Sevelamer from September 14, 2023, through September 18, 2023.
There was no documented evidence that the physician was notified that the Sevelamer was not available and not administered to Resident 6 with meals September 14 through 18, 2023.
Interview with the Director of Nursing on September 20, 2023, at 1:40 p.m. confirmed that there was no documented evidence that the physician was notified that the cefuroxime axetil and Sevelamer for Resident 6 were not available and not administered as ordered.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated regarding fall precaution interventions for ...
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Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated regarding fall precaution interventions for two of 10 residents reviewed (Residents 3, 8)
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 2, 2023, indicated that the resident was cognitively intact, was independent with bed mobility and transfers, and had a history of falls.
A nursing note, dated August 12, 2023, at 3:41 p.m. revealed that Resident 3 was observed sitting in his wheelchair in the bathroom. Blood was noted on the floor next to his bed, on his bed sheets, and on his clothing. A laceration was observed on the resident's forehead that measured 9.0 x 0.5 centimeters (cm) as well as a skin tear on his right forearm. When asked what happened, the resident stated he was sitting on his bed and leaned over to reach for something and fell off the bed and hit his head on the floor. He then got himself up into his wheelchair and wheeled into the bathroom. The Certified Registered Nurse Practitioner (CRNP) was notified and an order was received to send the resident to the hospital. A physician's order, dated August 14, 2023, included an order for a perimeter mattress (mattress with raised edges to prevent rolling out) to decrease the risk of falling from bed.
Observations on September 20, 2023, at 2:45 p.m. revealed that a perimeter mattress was on Resident 3's bed.
There was no documented evidence that Resident 3's care plan regarding fall prevention was revised to reflect the use of a perimeter mattress on his bed.
Interview with the RNAC (Registered Nurse Assessment Coordinator - responsible for developing and revising care plans) on September 28, 2023, at 2:52 p.m. confirmed that she was not aware that Resident 3 had a perimeter mattress ordered and the care plan should have been updated.
A quarterly MDS assessment for Resident 8, dated June 25, 2023, revealed that the resident was confused, required extensive assistance with mobility, and was not ambulatory.
A nursing note for Resident 8, dated August 6, 2023, indicated that on August 5, 2023, at 11:25 p.m. the resident rolled out of bed.
The CRNP note for Resident 8, dated August 7, 2023, indicated that her current bed had a bolster but an additional wedge was needed for her to maintain her bed positioning.
A CRNP order for Resident 8, dated August 7, 2023, included an order to add an extra bolster to the right side of her bed.
There was no documented evidence that Resident 8's care plan regarding fall prevention/positioning in bed was revised to reflect the use of an extra bolster on the right side of her bed.
Interview with the Assistant Director of Nursing on September 20, 2023 at 12:26 p.m. confirmed that the plan of care was not updated related to the resident's additional bolster to be in use and that it should have been updated.
28 Pa. Code 211.11(d) Resident care plan.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical records reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of 10 residents reviewed (Res...
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Based on clinical records reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for one of 10 residents reviewed (Resident 6).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 24, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance from staff for daily care needs, was incontinent of bladder, and had diagnoses that included a urinary tract infection within the past 30 days and end-stage renal (kidney) disease.
Physician's orders for Resident 6, dated September 14, 2023, included an order for the resident to receive 500 milligrams (mg) of cefuroxime axetil (antibiotic) twice a day for five days for a urinary tract infection.
The Medication Administration Record (MAR) for Resident 6, dated September 2023, indicated that the resident did not receive cefuroxime axetil on September 14, 2023, at 8:00 a.m. and 8:00 p.m. and September 18, 2023, at 8:00 a.m. due to not being available from the pharmacy.
There was no documented evidence that the cefuroxime axetil was administered to Resident 6 twice a day for five days as ordered by the physician.
Physician's order for Resident 6, dated September 14, 2023, included an order for the resident to receive 800 mg of Sevelamer HCl (used to control high blood levels of phosphorus in people with chronic kidney disease) with meals (8:00 a.m., 12:00 p.m., 5:00 p.m.) for end-stage renal failure.
The MAR for Resident 6, dated September 2023, indicated that the resident did not receive Sevelamer from September 14, 2023, through September 18, 2023.
A nursing note, dated September 18, 2023, at 3:12 p.m. revealed that the Sevelamer was discontinued and the resident ordered calcium acetate as per the pharmacy's recommendation.
There was no documented evidence that the Sevelamer was administered to Resident 6 with meals as ordered by the physician September 14 through 18, 2023.
Interview with the Director of Nursing on September 20, 2023, at 1:40 p.m. confirmed that Resident 6 did not receive the cefuroxime axetil and Sevelamer as ordered by the physician.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to attempt new interventions for fall prevention for one of the 10 residents reviewed (...
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Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to attempt new interventions for fall prevention for one of the 10 residents reviewed (Resident 3) and failed to ensure that fall prevention interventions were in place as ordered for one of 10 residents reviewed (Resident 8).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 2, 2023, indicated that the resident was cognitively intact, was independent with bed mobility and transfers, and had a history of falls.
A nursing note, dated June 24, 2023, at 4:45 a.m. revealed that Resident 3 was found on the floor with both legs bent at the knees. He said that he was getting out of bed and slid down to his knees. He had an abrasion on the left knee measuring 4.0 x 3.0 centimeters (cm) and two abrasions noted on the right knee measuring 1.0 x 1.0 cm and 4.0 x 2.5 cm.
There was no documented evidence that any new interventions were put into place to prevent falls for Resident 3.
Interview with the RNAC (Registered Nurse Assessment Coordinator - responsible for developing and revising care plans) on September 28, 2023, at 2:52 p.m. confirmed that there was no evidence that any new fall interventions were put into place following the resident's fall on June 24, 2023.
A quarterly MDS assessment for Resident 8, dated June 25, 2023, revealed that the resident was confused, required extensive assistance with mobility, and was not ambulatory,
A nursing note for Resident 8, dated August 6, 2023, indicated that on August 5, 2023, at 11:25 p.m. the resident rolled out of bed.
The Certified Registered Nurse Practitioner( CRNP- registered nurse with specialized training) note for Resident 8, dated August 7, 2023, indicated that her current bed had a bolster but an additional wedge was needed for her to maintain her bed positioning.
CRNP order for Resident 8, dated August 7, 2023, included an order to add an extra bolster to the right side of her bed.
Observations of Resident 8 on September 20, 2023, at 9:51 a.m. during care and at 11:28 a.m. revealed that the resident was in bed and that there was no extra bolster placed on the right side of the bed. There was a bolster noted in her room on her chair.
Interview with Licensed Practical Nurse 1 on September 20, 2023, at 11:28 a.m. indicated that the resident should have the bolster in use when in bed because she tends to lean to the right.
Interview with the Nursing Home Administrator on September 20, 2023, at 12:09 p.m. indicated that the bolster should have been in place.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Based on clinical records reviews and staff interviews, it was determined that the facility failed to ensure that a resident's clinical record was complete and accurately documented for one of 10 resi...
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Based on clinical records reviews and staff interviews, it was determined that the facility failed to ensure that a resident's clinical record was complete and accurately documented for one of 10 residents reviewed (Resident 6).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 6, dated September 24, 2023, indicated that the resident was cognitively intact, required limited to extensive assistance from staff for daily care needs, did not receive bathing during the review period, and received dialysis. Physician's orders, dated July 12, 2023, revealed that the resident received dialysis every Tuesday, Thursday and Saturday.
A shower/bathing record, dated December 21, 2022, revealed that Resident 6 was to receive a bath/shower during the evening on non-dialysis days. Nurse aide documentation for August and September 2023 revealed no documented evidence that Resident 6 received a shower from August 1 through 14 and September 1 through September 7, 2023.
Interview with Resident 6 on September 20, 2023, at 8:43 a.m. revealed that she was receiving her scheduled showers/baths.
Interview with the Assistant Director of Nursing on September 20, 2023, at 4:16 p.m. confirmed that there was no documentation of Resident 6's bathing/showers during the mentioned time frames.
28 Pa. Code 211.5(f) Clinical records.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during car...
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Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to use proper infection control practices during care for one of 10 residents reviewed (Resident 8).
Findings include:
The facility policy for handwashing/hygiene, dated November 17, 2022, indicated that the use of gloves do not replace handwashing/hygiene. Hand hygiene is the final step after removing and disposing of personal protective equipment.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated June 5, 2023, revealed that the resident was frequently incontinent of bowel and bladder and required extensive assistance of two for hygiene.
Physician's orders for Resident 8, dated September 6, 2023, indicated that she had a pressure ulcer on her right and left buttocks and the wounds were to be cleaned with soap and water, apply zinc, and then apply a foam dressing three times a day and as needed.
Observations of Resident 8 during hygiene and wound care on September 20, 2023, at 9:51 a.m. revealed that the resident was removed from a bedpan, she had smeared bowel on her buttocks and with gloves on Licensed Practical Nurse 1 cleaned the resident. After providing her care she removed her gloves, and without performing hand hygiene, she donned new gloves and proceeded to provide wound care to the resident's right and left buttocks.
Interview with Licensed Practical Nurse 1 on September 20, 2023, at 10:11 a m. revealed that she should have washed her hands after removing her gloves.
Interview with the Nursing Home Administrator on September 20, 2023, at 12:09 p.m. confirmed that Licensed Practical Nurse 1 should have washed her hands after providing hygiene care to Resident 8 and removing her gloves.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
Jun 2023
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise residents' care plans with individualized intervent...
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Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to revise residents' care plans with individualized interventions to address their care needs for one of three residents reviewed (Resident 2).
Findings include:
The facility's policy regarding minimum data set completion, dated November 17, 2023, indicated that the care plan shall include measurable objectives with interventions based on the resident's care needs and means of achieving each goal. The care plan shall be based on oral and written communication resident, family interviews, and assessments provided by nursing, dietary, resident activities, and social work staff when ordered by the physician or advanced practice nurse, and assessments shall also be provided by other health care professionals.
A quarterly Minimum Data Set (MDS) assessment (mandated assessment of a resident's abilities and care needs) for Resident 2, dated March 15, 2023, indicated that the resident was cognitively intact, understood, could understand, and required assistance from staff for his daily care tasks.
A consult telemedicine note for Resident 2, dated June 7, 2023, revealed the resident stated he would harm others and has a plan to do so. Resident 2 planned to get a gun through his window from a neighbor friend that had a motorcycle. His planned to get the gun on a good day when he had the time. The resident has a history of violence toward women and his wife. This information was reported to the facility with the recommendation to 302 (involuntary commitment is an application for emergency evaluation and treatment for persons who are a danger to themselves or others due to a mental illness) the resident.
An interview with the Social Services Director on June 13, 2023, at 1:29 p.m. confirmed that Resident 2, had recently made threats of harm against staff and had a history of harm against staff in the past by choking a staff member. The crisis team determined that he did not meet the criteria for involuntary commitment, due to his plan had changed.
A concern grievance report for Resident 2, dated June 9, 2023, revealed that the resident reported that he did not receive care all night long when the call light on. Upon investigation Resident 2 confirmed that care was given and he changed his story. Interviews with staff determined that all care was provided and the concern was not founded.
A nursing note dated June 9, 2023, indicated that the nurse aide staff did not feel comfortable interacting with Resident 2 due to resident's previous documented threat, for which the crisis team was called for intervention. A plan to have the scheduled registered nurse and licensed practical nurse would provide all care.
There was no documented evidence that Resident 2's care plan was revised and updated to include the history of behavior of making false statements.
An interview with the Social Services Director on June 13, 2023, at 1:29 p.m. confirmed that Resident 2, had recently made threats of harm against staff, had a history of threats of violence towards facility staff, had physically attacked staff, and has made statements of threats of harm or neglect from staff and then retracts them.
Interview with the Director of Nursing (DON) on June 13, 2023, at 2:05 p.m., revealed DON instructed staff to increase monitoring Resident 2 during rounds, and document every shift in the progress notes.
Interview with the Nursing Home Administator on June 13, 2023, at 5:53 p.m., confirmed that Resident 2's behavior care plan did not include his false statements and allegations.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
Feb 2023
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a registered nurse license check prior to hire for one of one regis...
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Based on review of policies and personnel files, as well as staff interviews, it was determined that the facility failed to complete a registered nurse license check prior to hire for one of one registered nurse reviewed (Registered Nurse 1).
Findings include:
The facility's abuse policy, dated November 17, 2022, indicated that the facility would conduct employee background checks and not knowingly employ or otherwise engage any individual who has a disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property.
Review of personnel file for Registered Nurse 1 revealed that she was hired on October 26, 2022, and the Pennsylvania Professional Licensure check was not verified as of February 1, 2023, four months after she was hired.
Interview with Director of Nursing on February 1, 2023, at 1:34 p.m. confirmed there was no documented evidence that standing on the Pennsylvania Professional Licensure Registry was verified for Registered Nurse 1 prior to her hire date.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1)Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that Quarterly Minimum Data ...
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Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that Quarterly Minimum Data Set assessments were completed within the required timeframe for seven of 24 residents reviewed (Residents 2, 3, 6, 8, 11, 21, 22).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), dated October 2019, indicated that the completion date for a quarterly assessment is the Assessment Reference Date (ARD - the last day of an assessment's look-back period) plus 14 days. A quarterly assessment is due every 92 days (ARD of most recent assessment + 92 days).
A quarterly MDS assessment for Resident 2, with an ARD of December 15, 2022, was completed on January 1, 2023, which was four days late.
A quarterly MDS assessment for Resident 3, with an ARD of November 1, 2022, was completed 96 days after the last MDS, four days late.
A quarterly MDS assessment for Resident 6, with an ARD of November 13, 2022, was completed on November 28, 2022, which was two days late.
A quarterly MDS assessment for Resident 8, with an ARD of December 11, 2022, was completed on December 26, 2022, which was two days late.
A quarterly MDS assessment for Resident 11, with an ARD of December 3, 2022, was completed on December 19, 2022, which was three days late.
A quarterly MDS assessment for Resident 21, with an ARD of August 31, 2022, was completed on November 30, 2022, which was 74 days late.
A quarterly MDS assessment for Resident 22, with an ARD of October 28, 2022, was completed on November 14, 2022, which was 4 days late.
Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on February 1, 2023, at 12:48 p.m. confirmed that the MDS's were not completed within the required timeframe.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed for one of 24 residents reviewed (Resident 35) who was a recent admission.
Findings include:
The facility's policy regarding baseline care plans, dated November 17, 2022, indicated that the baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident.
An admission nursing note for Resident 35, dated January 19, 2023, revealed that the resident was admitted to the facility on [DATE], following a fall at home. At the hospital, the resident was cardioverted (procedure to restore normal heart rhythm), and was now wearing a life vest (personal defibrillator that will send a shock to restore normal heart rhythm) with a battery that was to charge at the bedside.
Physician's orders for Resident 35, dated January 19, 2023, included an order for the life vest to be checked for placement and functioning every shift, may remove for showering, and to change the battery every day on day shift and place the old battery into the charger to charge overnight.
Observations and an interview on January 31, 2023, at 3:30 p.m. with Resident 35 revealed that the resident was in bed watching television, had no unmet needs, and was wearing the life vest. There was no documented evidence that the baseline care plan contained information regarding the use of a life vest.
Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for completion of MDS assessments) on February 1, 2023, at 11:28 a.m. confirmed that Resident 35's baseline care plan did not contain information regarding the use of life vest, and that it should have.
28 Pa. Code 211.11(d) Resident care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff and resident interviews, it was determined that the facility failed to clarify physician's orders for oxygen use for one of 24 residents reviewed ...
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Based on review of clinical records, as well as staff and resident interviews, it was determined that the facility failed to clarify physician's orders for oxygen use for one of 24 residents reviewed (Resident 17).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated January 10, 2023, indicated that the resident was cognitively intact and required assistance from staff for his daily care tasks.
Interview with Resident 17 on January 30, 2023, at 10:35 a.m. revealed that he felt that he did not need oxygen and did not understand why it was ever ordered.
Physicians orders for Resident 17, dated January 18, 2023, included an order for 2 liters of oxygen per minute via nasal cannula (tubing placed at the nostrils for oxygen delivery) every shift; however, there was no documented evidence of an assessment indicating the need for oxygen or communication with the physician for clarification of the order.
Interview with the Director of Nursing on January 31, 2023, at 3:30 p.m. confirmed that there was no documented evidence of an assessment indicating a need for oxygen for Resident 17 or a clarification of the order.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of residents for five ...
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Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to provide adequate, ongoing activities designed to meet the needs of residents for five of 24 residents reviewed (Residents 10, 17, 20, 21, 34).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated November 7, 2022, indicated that the resident was cognitively intact and required staff assistance for daily care needs. Resident 10's care plan, dated November 4, 2022, indicated that she enjoyed activities such as BINGO, music, chatting, pets, group activities, arts/crafts, current events, outdoors and religious/spiritual.
A comprehensive MDS assessment for Resident 17, dated January 10, 2023, revealed that the resident was cognitively intact and required staff assistance for his daily care needs. Resident 17's care plan, dated January 9, 2023, indicated that he enjoyed activities such as reading, word searches, pets/animals, group activities, current events, chatting, outdoors and religious/spiritual.
A comprehensive MDS assessment for Resident 20, dated November 9, 2022, indicated that the resident was cognitively intact and required assistance from staff for her daily care needs. Resident 20's care plan, dated December 16, 2020, indicated that she enjoyed activities such as chatting, oldies music, pets/animals, outdoors, TV, card games and outings.
A comprehensive MDS assessment for Resident 21, dated August 21, 2022, revealed that the resident was cognitively intact and that he required assistance from staff for his daily care needs. Resident 21's care, dated January 18, 2023, indicated that he enjoyed activities such as music, pets/animals, BINGO, group activities, cooking/baking, volunteering at community center, TV, outdoors and religious/spiritual.
A care plan for Resident 34, dated January 19, 2023, indicated that he enjoyed activities such as cooking, music, pets/animals, group activities, outdoors, fishing, coloring books, chatting, card games, and spending time with his family.
A review of the activity calendar, dated January and February 2023, revealed that there were no activities scheduled for the weekends, before 2:00 p.m. on any weekday, or after 6:30 p.m. on any week night.
An interview with Residents 10, 17, 20, 21 and 34 on January 30, 2023 at 3:30 p.m. revealed that the residents would like more activities. They stated that there are no coordinated activities on Saturdays or Sundays and that there is nothing to do before lunch or after the evening meal during the week. They stated that the Activity Director is the only staff member in the department and that he does what he can but cannot be at the facility everyday.
Interview with the Activity Director on February 1, 2023, at 10:47 a.m. revealed that he was aware that the residents would like more activities through the week, as well as activites on the weekend; however, as the only activity staff, he could not be present seven days a week. Further, he stated that he had to complete required documentation for each resident and attend meetings, as well as hold the activities.
Interview with the Nursing Home Administrator on February 1, 2023, at 5:25 p.m. confirmed that there were no activities on the weekends, no activities before 2:00 p.m. or after 6:30 p.m. during the week, and that the residents would like there to be.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to complete neurological assessments after a fall or have a professional (registered) nurse...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to complete neurological assessments after a fall or have a professional (registered) nurse assess a resident at the time of death for one of 24 residents reviewed (Resident 32), and failed to follow physician's orders for two of 24 residents reviewed (Residents 17, 18).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated June 20, 2022, indicated that the resident was cognitively intact and required assistance from staff for his daily care tasks.
A nursing note, dated July 9, 2022, at 9:40 p.m., revealed that Resident 32 had an unwitnessed fall in his room and he was unable to verbalize what happened. A nursing note, dated July 9, 2022, at 10:24 p.m. revealed that the resident's vital signs were last obtained prior to his fall at 9:00 p.m.
A fall investigation report for Resident 32, dated July 9, 2022, indicated that staff were to do neurochecks (a thorough assessment to assess mental status, cranial nerves, motor and sensory function, as well as reflexes to determine if there has been a change in mental or physical function) on the resident; however, there was no documented evidence that any neurochecks were completed.
A nursing note, dated July 10, 2022, at 6:11 a.m., revealed that the resident had ceased to breathe and the facility called the funeral home. There was no documented evidence that a registered nurse assessed the resident at the time of his death to document where he was found or how he was positioned.
Interview with the Assistant Director of Nursing on Feburary 1, 2023, at 5:09 p.m. confirmed that there was no documented evidence that Resident 32 had been assessed any time between his fall on July 9 at 9:00 p.m. and when he was found dead at 6:10 a.m. She confirmed that a registered nurse should have assessed the resident at the time of his death and documented the assessment in the resident's clinical record.
An admission MDS assessment for Resident 17, dated January 30, 2022, revealed that Resident 17 was understood, could understand, and required limited assistance for transfers.
Physician's orders for Resident 17, dated January 18, 2023, included an order to be evaluated by Wound Healing Solutions on their next rounds for bilateral lower extremity edema and an open area to his left lower extremity.
There was no documented evidence in Resident 17's clinical record to indicate that he was examined by Wound Healing Solutions per physician orders.
Interview with the Director of Nursing on January 31, 2023, confirmed that Resident 17 should have been evaluated by Wound Healing Solutions per physician orders and he was not.
The facility's policy for measuring blood pressure, dated November 17, 2022, indicated that the purpose of the procedure was to measure the pressure exerted by the circulating volume of blood on the walls of the arteries, veins, and chambers of the heart. Hypotension was defined as blood pressure less than 100/60 millimeters of mercury (mm/Hg).
A quarterly MDS assessment for Resident 18, dated December 27, 2022, revealed that Resident 18 was understood, could understand, was cognitively intact, required limited assistance to extensive assistance for care, had diagnoses that included heart failure and hypertension (high blood pressure), and required hemodialysis (procedure that filters waste and excess fluid from the blood).
Physician's orders for Resident 18, dated September 25, 2022, included an order for the resident to receive 2.5 milligrams of Lisinopril (used to treat high blood pressure) every Monday, Wednesday, and Friday for hypertension.
Observations of the medication pass on February 1, 2023, at 7:38 a.m. revealed that the medication card had directions for the medication to be held if the systolic blood pressure was less than 100 mm/Hg. Interview with Licenced Practical Nurse 1, following the medication pass, revealed that the blood pressure parameters were missed because they did not come up on the computer screen.
A review of Resident 18's medical record revealed no documented evidence that the blood pressure was recorded prior to administration of the medication for the month of January 2023, with the exception of January 23, 2023.
Interview with the Assistant Director of Nursing on February 1, 2023, at 10:16 a.m. and 10:21 a.m. confirmed that Resident 18 did not have documented evidence that the blood pressure was checked prior to administration of blood pressure medication.
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 a review of the facility's policies and clinical records, as well as staff interviews, it was determined that the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care-planned interventions and physican's orders were followed for a resident with a significant weight loss for one of 24 residents reviewed (Resident 23).
Findings include:
The facility's policy regarding unplanned weight loss, dated November 17, 2022, indicated that the staff and physician would define the individual's current nutritional status and weight loss. The staff would report to the physician about significant weight loss from baseline appetite or food intake. The physician and staff would collaborate in adjusting interventions, taking into account the status of those causes and the resident's responses and wishes.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated January 12, 2023, revealed that the resident was cognitively intact, was understood, could understand, and could feed himself after set up by staff. Resident 23's care plan, dated January 9, 2023, indicated that the resident had actual weigh loss with poor intake and that his food preferences should be honored. The resident was admitted on [DATE].
Resident 23's admission weight on January 6, 2023, was 126.5 pounds. His weight on January 27, 2023 was 117 pounds, indicating a 9.5-pound weight loss.
Physician's orders for Resident 23, dated January 28, 2023, included an order for the resident to have four ounces of nutritious treats (Magic Cups) two times a day.
A nutrition note for Resident 23, dated January 28, 2023, indicated that the resident had a significant weight loss since admission and included a recommendation to add nutritious treats twice a day with lunch and dinner to help further meet needs and prevent further loss from occurring. Will continue to monitor the resident for changes in status. The physician was also made aware of the recommendations.
A review of Resident 23's Treatment Administration Record for January 2023 revealed that he did not receive a magic cup with lunch and dinner on January 28 and 29, or with supper on January 31. Documentation for the lunch meal on January 31, 2023, indicated that the resident refused, but there were no Magic Cups available at that time.
Observations during the breakfast meal on January 31, 2023, at 7:52 a.m. revealed that Resident 23's meal ticket revealed that he disliked eggs. His breakfast tray was prepared with scrambled eggs, a scoop of mechanical processed sausage, a bowl of cheerios, and two beverages. Interview with the Resident 23 at that time confirmed that he does not eat eggs.
Interview with Nures Aide 1 on January 31, 2023, at 8:05 a.m. confirmed that Resident 23 was served eggs, that he did not eat the eggs, and that his meal ticket indicated that he disliked eggs.
Interview with the Consultant Registered Dietitian on January 31, 2023, at 12:43 p.m. confirmed that she would expect supplements to be substituted if they were not available, and that food preferences should be honored.
Interview with the Cook/Dietary Manager on January 31, 2023, at 3:31 p.m. confirmed that there were no magic cups available, she was not informed from kitchen staff that there were no magic cups in stock, and she further planned to meet with the facility's Dietitian to explore fortified pudding or other food additives.
Interview with the Director of Nursing on February 1, 2023, at 1:34 p.m. confirmed that Resident 23 should have been offered food according to preferences and that the nutritious supplements should have been substituted to meet his nutritional needs.
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on a review of manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to label medications with the date they were opened for one o...
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Based on a review of manufacturer's instructions, as well as observations and staff interviews, it was determined that the facility failed to label medications with the date they were opened for one of one bottles in the medication refrigerator.
Findings include:
Tubersol Manufacturer's Instructions, dated November 1, 2021, indicated that a multi-dose vial of Tubersol solution should be discarded 30 days after it is opened.
Observations in the facility's medication room refrigerator on February 1, 2023, at 11:50 a.m. revealed one opened and undated bottle of Tubersol Tuberculin injection for Mantoux TB skin test (to test for tuberculosis).
Interview with Licensed Practical Nurse 2 on February 1, 2023, at 11:50 a.m. confirmed that the bottle of Tubersol was not dated when it was opened, and that it should have been.
Interview with the Director of Nursing on February 1, 2023, at 1:34 p.m. confirmed that the opened vial of Tubersol should have been dated when opened.
28 Pa. Code 211.9(a)(1) Pharmacy services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that each resident was offered and received influenza immunizations for one of five residents reviewed (Resident 33).
Findings include:
The facility's policy regarding influenza vaccines for residents, dated November 17, 2022, revealed that residents are offered vaccines in a timely, safe, and appropriate manner. The influenza vaccine would be offered to each resident October 1 through March 31, unless the immunization is medically contraindicated or the resident had already been immunized during the time period.
A Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) entry tracking record for Resident 33 indicated that the resident was admitted to the facility on [DATE].
An informed consent for influenza vaccination, signed by Resident 33 on January 17, 2023, indicated that the resident gave the facility permission to administer the influenza vaccination, unless medically contraindicated. There was no documented evidence in the clinical record to indicate that Resident 33 received the influenza vaccine.
Interview with the Assistant Director of Nursing/Infection Preventionist on February 1, 2023, at 2:18 p.m. confirmed that Resident 33 signed an informed consent to receive the influenza vaccine on admission, but did not receive the vaccination and should have.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, was well as observations and resident and staff interviews, it was determined that the facility failed to maintain essential resident care equipment i...
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Based on review of policies and clinical records, was well as observations and resident and staff interviews, it was determined that the facility failed to maintain essential resident care equipment in a safe manner for one of 24 residents reviewed (Resident 23).
Findings include:
The facility's policy regarding bed safety, dated November 17, 2022, indicated that the facility shall strive to provide a safe sleeping environment for the resident. The facility shall provide inspections by maintenance staff of all beds and related equipment as part of a regular bed safety program to identify risks and problems.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated January 12, 2023, revealed that the resident was cognitively intact, was understood, could understand, and required extensive assistance for activities of daily living.
Observations and interview with Resident 23 on January 30, 2023, at 11:05 a.m. and January 31, 2023, at 9:44 a.m. revealed that the bed controls were not working and that Resident 34 was concerned for facility staff who have to assist him with care.
Interview with the Director of Maintenance on January 31, 2023 at 11:39 a.m. revealed that he was aware that the bed was not working in the pas, but was not aware of on-going issues. He said that the system locked out and needed to be reset. The Director of Maintenance attempted to reset the system, but the bed controls did not function for more than a few seconds. The Maintenance Director determined that there was a loose connection, and agreed that the bed should be in a safe working condition. The Director of Maintance attempted to repair the bed, but at 12:05 p.m., he replaced the bed. He was unable to provide any documentation about the previous maintenance on the bed.
Interview with the Maintenance Director on January 31, 2023, at 2:22 p.m. confirmed that the bed was not functioning properly, needed to be replaced, and that he had checked all of the beds in the facility.
28 Pa. Code 207.2(a) Administrator's responsibility.
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 review of clinical records and grievance records, as well as staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance for two of 24 resident...
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Based on review of clinical records and grievance records, as well as staff interviews, it was determined that the facility failed to make ongoing efforts to resolve a grievance for two of 24 residents reviewed (Residents 1, 24).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated October 27, 2022, revealed that the resident was alert and oriented and required assistance for daily care needs, including with her meals.
A grievance for Resident 1, dated November 18, 2022, indicated that the resident did not care for the meal and that it was a very small amount of food on her tray. The facility's resolution to the portion size on her tray was for the resident to have larger portions.
An interview with Resident 1 on January 30, 2023, at 11:10 a.m. revealed that the food has no taste, she does not get enough food on her trays for meals, and that she is not offered an alternative. She stated that when she attempted to get an alternative from the kitchen she was told there was nothing left from the meal, or that she was supposed to call at least an hour prior to the meal being served in order to get the alternative.
A quarterly MDS assessment for Resident 24, dated December 20, 2022, indicated that the resident was alert and oriented and could feed herself after set up by staff.
A grievance for Resident 24, dated November 18, 2022, indicated that the resident was not satisfied with the dinner and that the portion size was too small. The facility's resolution to the portion size was for the resident to have larger portions.
Observations of tray preperation on January 31, 2023, at 11:20 a.m. revealed that the cook was not using the proper portion size utensils for serving food and that residents were not getting the appropriate portion size of food on their trays. Further observations of Resident 24's meal tray at that time revealed that she had a dislike of corn and was a vegetarian. Her lunch tray was prepared with one scoop of mashed potatoes and one scoop of mixed vegetables, which consisted mostly of corn (one of her dislikes) and a four-ounce yogurt.
An interview with Resident 24 on January 30, 2023 at 1:50 p.m. revealed that she does not get the food she is supposed to get on her trays and that the facility does not provide her with a nutritious meal since she is a vegetarian. She stated that she does not get double portions or larger portions and that the kitchen staff have told her to have her family bring in food from home. She further stated there is often food on her tray that the kitchen staff are aware that she does not like (such as corn).
Interview with the Dietary Consultant on January 31, 2023, at 12:33 p.m. revealed that residents should get a tray with the appropriate size portions and foods that they like.
Interview with the Nursing Home Administrator on Feburary 1, 2023, at 5:25 p.m. confirmed that the food concerns brought to the staff's attention by Residents 1 and 24 were not resolved to the residents' satisfaction.
28 Pa. Code 201.29(i) Resident rights.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on review of facility policies, written and posted menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu and portion sizes ...
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Based on review of facility policies, written and posted menus, as well as observations and staff interviews, it was determined that the facility failed to follow their planned menu and portion sizes for one of one meal observed.
Findings include:
The facility's policy for menu changes, dated November 17, 2022, indicated that the facility must have a recipe on file for all menu items.
Interview with a group of residents on January 30, 2023, at 3:30 p.m. revealed that the food is bland, the hot food is usually cold, the portion sizes are too small, and they never get the food that is advertised on the menu or they are told that the menu has changed.
The facility's written menu for the lunch meal on January 31, 2023, revealed that the residents were to receive Salisbury steak, fried potatoes, buttered corn, dinner roll, peaches, beverage of choice, margarine and pepper.
Observations during the lunch meal on January 31, 2023, at 11:45 a.m. revealed that residents who received a regular diet were served kielbasa that was cut up into chunks and mixed with sauerkraut, mashed potatoes (some with beef gravy, some with no gravy), mixed vegetables (corn mixed with green beans), applesauce and a beverage. There was no Salisbury steak, fried potatoes, buttered corn, dinner roll or peaches. As Cook/Dietary Manager 1 prepared the lunch trays, she used a pair of tongues to serve the sauerkraut and kielbasa mix. Observations of the meals that were served to the residents revealed that the portions of kielbasa and sauerkraut differed in size.
Interview with the Cook/Dietary Manager on January 31, 2023 at 12:15 p.m. confirmed that the posted menu was changed that day and that she believed the nurse aides were responsible for informing the residents of the change. She was not aware of any residents that were informed of the change. She further stated that she believed she knew how much food the residents would eat and that is why she gave various amounts of the sauerkraut and kielbasa mix. She stated that the residents did not receive a whole piece of kielbasa because she believed it was easier for them to eat if it was already cut up into pieces for them, even the regular diets who did not require their meat cup up prior to serving. She further stated that the residents did not eat much and that was why they received small servings on their plates. She was not able to produce a written recipe for the lunch meal that was served, which would have indicated the portion sizes of each food item to be given.
Interview with the Dietary Consultant on January 23, 2023, at 12:33 p.m. revealed that the cook should have followed the menu as posted, or notified the residents of the change, if the change was necessary. She further indicated that the cook should have followed the menu/spreadsheet for the meal and used the appropriate serving utensils to ensure each resident received a nutritious meal.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 211.6(b) Dietary services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on review of policies, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable, at proper temperatures, or pr...
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Based on review of policies, as well as observations and interviews with residents and staff, it was determined that the facility failed to serve food that was palatable, at proper temperatures, or prepared according to the recipe.
Findings include:
The facility's policy regarding food temperatures, dated November 17, 2022, indicated that food that was served was to be within the range of 120-140 degrees Fahrenheit and based on the residents' preferences.
Resident Council Meeting minutes for November 9, 2022, revealed that the residents reported that the sauce the previous night was cold and the food council was to be made aware.
Interview with a group of residents on January 30, 2023, at 3:30 p.m. revealed that the hot food is usually cold, the portion sizes are too small, they never get the food that is advertised on the menu, nor are they told that the menu has changed, and the food is bland.
Interview with Resident 7 on January 30, 2023, at 12:49 p.m. revealed that she did not like the food because it never tastes good, the hot food is usually cold, the portion sizes are too small, and it is impossible to get an alternative. She further stated that she never gets what is advertised on the menu.
Interview with Resident 29 on January 30, 2023, at 12:54 p.m. revealed that she does not like the food. She stated that it was tasteless and cold. She said that the portion sizes are very small, and she has her family bring food in for her so that she is not hungry. She had fast food that she was eating with her daughter at that time.
Observations in the kitchen on January 31, 2023, at 11:54 a.m. revealed that a test tray was placed on the lunch meal cart going to the last hall. The cart arrived on the unit at 11:54 a.m., and the last resident was served and eating at 12:02 p.m. At 12:02 p.m. the temperature of the sauerkraut and kielbasa mix was 131.8 degrees Fahrenheit. The sauerkraut and kielbasa was lukewarm and not hot to taste, and was not palatable at that temperature.
Interview with the [NAME] on January 31, 2023, at 12:15 p.m. revealed that she would have liked the hot foods be served at a little higher temperature but that she believed the dietary aide may have turned the steam table down during meal prep because of it being hot from the steam.
A quarterly MDS assessment for Resident 18, dated December 27, 2022, revealed that Resident 18 was understood, could understand, was cognitively intact, and was independent with eating after set up.
The facility's recipe for scrambled eggs included black pepper, salt, and melted margarine.
Observations of the meal preparation for breakfast on January 31, 2023, at 7:18 a.m. revealed that breakfast service was delayed because the refrigerated liquid eggs were shipped frozen and did not thaw completely. At 7:26 a.m., the Cook/Dietary Manager, who was preparing pureed scrambled eggs, used water from the spray hose located above the three-bin sink to add to the eggs. The eggs were sampled at 7:44 a.m., tasted bland, and were not palatable. Interview with Resident 18 on January 31, 2023, at 8:02 a.m. revealed that the eggs were not good.
Interview with the Consultant Registered Dietitian on January 31, 2023, at 12:43 p.m. confirmed that another source of water would have been preferred to make the pureed eggs and that the scrambled eggs did not appear to be made according to the recipe, as there was no black pepper visible. The scrambled eggs should have been prepared according to the recipe.
Interview with the Cook/Dietary Manager on January 31, 2023, at 3:31 p.m. revealed that she was never informed not to use the spray hose above the dishwashing sinks to add water to the food.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 211.6(c) Dietary 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 F0806
(Tag F0806)
Could have caused harm · This affected multiple residents
Based on review of facility policies and clinical records, as well as observations and interviews with residents and staff, it was determined that the facility failed to honor residents' food preferen...
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Based on review of facility policies and clinical records, as well as observations and interviews with residents and staff, it was determined that the facility failed to honor residents' food preferences for two of 24 residents reviewed (Residents 23, 24).
Findings include:
The facility's policy on food preferences, dated November 17, 2022, indicated that the facility shall identify a resident's food preference with in 24 hours of admission. If the resident refuses or was unhappy with the diet, staff would create a care plan that satisfied the resident.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated January 12, 2023, revealed that the resident was cognitively intact, was understood, could understand, and could feed himself after set up by staff. Resident 23's care plan, dated January 9, 2023, indicated that the resident had actual weight loss with poor intake and that his food preferences should be honored.
Interview with Resident 23 on January 30, 2023, at 11:05 a.m. revealed that he has lost weight, does not like eggs but was being served eggs in the morning, and that his meal slips indicated that he disliked eggs.
Observations during the breakfast meal on January 31, 2023, at 7:52 a.m. revealed that Resident 23's breakfast ticket stated that he disliked eggs. His breakfast tray was prepared with scrambled eggs, a scoop of mechanical processed sausage, a bowl of cheerios, and two beverages. Interview with the Resident 23 at that time revealed that he does not eat eggs.
Interview with Nurse Aide 1 on January 31, 2023, at 8:05 a.m. confirmed that Resident 23 was served eggs, that he did not eat the eggs, and that his meal ticket indicated that he disliked eggs.
Interview with the Cook/Dietary Manager on January 31, 2023, at 3:29 p.m. confirmed that Resident 23 should not have had eggs on his breakfast tray, and a substitution should have been made per his preferences.
A quarterly MDS assessment for Resident 24, dated December 20, 2022, indicated that the resident was alert and oriented and could feed herself after set up by staff. Resident 24's care plan, dated December 21, 2021, indicated that the resident was at risk for weight loss with poor intake and that her food preferences should be honored.
The facility's written menu for the lunch meal on Tuesday, January 31, 2023, revealed that residents were to have Salisbury steak, mashed potatoes, buttered corn, dinner roll, peaches, margarine and beverage of choice.
Observations during the lunch meal on January 31, 2023, at 11:54 a.m. revealed that Resident 24's lunch ticket stated that she was a vegetarian and that one of her dislikes was corn. Her lunch tray was prepared with a scoop of mashed potatoes, a scoop of mixed vegetables (corn and green beans), a small yogurt, and a beverage.
Interview with Resident 24 on January 30, 2023, at 1:50 p.m. revealed that she is a vegetarian and does not get adequate food on her tray. She stated that she rarely gets enough food on her tray for a meal and has to have her family bring food in from home for her.
Interview with the Cook/Dietary Manager on January 31, 2023, at 12:15 p.m. confirmed that Resident 24 did not like corn and was served corn. She stated that since the resident was a vegetarian she did not have anything to offer her as a replacement to the lunch food that was served (sauerkraut and kielbasa mix). She stated that the yogurt would have to serve has her protein for the meal, but she was not sure if it was the correct amount of protein for her diet. She stated she did not have a vegetarian menu to follow for the resident.
28 Pa. Code 211.6(a) Dietary services.
28 Pa. Code 201.29(j) Resident rights.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI...
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Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.
Findings include:
The facility's deficiencies and plans of correction for State Survey and Certification (Department of Health) survey ending February 24, 2022, and complaint survey ending December 6, 2022, revealed that the facility developed plans of correction that included quality assurance systems with audits to ensure that the facility maintained compliance with cited nursing home regulations. The results of the audits were to be reported to the QAPI committee for review. The results of the current survey, ending February 1, 2023, identified repeated deficiencies regarding baseline care plan, ensuring that physician's orders were followed, ensuring the physician was notified of weight loss, ensuring medication was dated and labeled, ensuring that the resident's meals were palatable and served at proper temperature.
The facility's plans of correction for deficiencies regarding the development of resident-centered care plans, cited during the survey ending February 10, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F655, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding the completion of resident baseline care plans.
The facility's plans of correction for deficiencies regarding ensuring that the physician orders were followed, cited during the survey ending on February 10, 2022, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring that the physician's orders were followed.
The facility's plans of correction for deficiencies regarding weight loss notification and timely response, cited during the surveys ending February 10, 2022, and complaint survey ending December 6, 2022, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F692, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding notification and timely treatment of weight loss.
The facility's plans of correction for deficiencies regarding ensuring that the medication was stored and labeled, cited during the survey ending on February 10, 2022, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F761, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring medication was stored and labeled appropriately.
The facility's plans of correction for deficiencies regarding ensuring that food was palatable and at proper serving temperatures, cited during the survey ending on February 10, 2022, revealed that audits would be conducted and the results of the audits would be brought before the QAPI committee for further monitoring. The results of the current survey, cited under F804, revealed that the QAPI committee was ineffective in maintaining compliance with the regulation regarding ensuring the food was palatable and had proper serving temperatures.
Refer to F655, F684, F692, F761, F804.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
Dec 2022
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 F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on a review of the facility's policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that there were timely resident re-weighs and notifica...
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Based on a review of the facility's policies, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that there were timely resident re-weighs and notification with intervention for a significant weight loss for one of six residents reviewed (Resident 2).
Findings include:
The facility's policy regarding weight management, dated July 14, 2022, indicated that if a resident's weight has a change of five percent or more since the last weight assessment, it will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietician in writing. Verbal notification must be confirmed in writing. The physician will also be notified of a significant weight change. The facility policy for weighing and measuring, dated July 14, 2022, indicated that staff are to report any significant weight loss or gain to the nursing supervisor.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 5, 2022, revealed that the resident was cognitively impaired and was dependent on staff for daily care including eating. The resident's weight records revealed that she experienced a 13.7 pound weight loss in two weeks when her weight dropped from 117.2 pounds on September 30, 2022, to 103.5 pounds on October 14, 2022. A dietary note, dated October 19, 2022, indicated that the resident had a significant weight loss of 11 percent in two weeks and recommendations were made for nutritious treats three times a day with meals, and that she was waiting on a re-weigh to confirm the weight loss, to further assess the resident's needs, and notify the physician.
There was no documented evidence that Resident 2 was re-weighed according to the facility's policy on October 15, 2022, or on October 19, 2022, after the dietician indicated the need for it to be completed to confirm the weight loss.
A dietician's note, dated October 26, 2022, revealed that Resident 2's weight on October 21, 2022, was 100 pounds, showing an overall weight loss of 20.4 pounds or 16.4 percent in 30 days, which was significant. Review of the resident's clinical record revealed that she was not taking her 2.0 supplement (nutritional shake) three times per day. It was recommended that she would have it changed to Ensure (nutritional shake) twice a day with her lunch and supper. There was no documented evidence that the physician was notified of the significant weight loss until October 26, 2022 (12 days after the weight loss was identified).
Interview with the Director of Nursing on December 6, 2022, at 1:31 p.m. confirmed that there was no documented evidence that Resident 2 was re-weighed until October 21, 2022, or that her weight loss was noted until October 19, 2022 (five days after her weight loss was first noted).
28 Pa. Code 211.12(d)(3) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Concerns
- • 53 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade D (45/100). Below average facility with significant concerns.
- • 61% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Scottdale Healthcare & Rehabilitation Center's CMS Rating?
CMS assigns SCOTTDALE HEALTHCARE & REHABILITATION CENTER an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Scottdale Healthcare & Rehabilitation Center Staffed?
CMS rates SCOTTDALE HEALTHCARE & REHABILITATION CENTER's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 61%, which is 15 percentage points above the Pennsylvania average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs.
What Have Inspectors Found at Scottdale Healthcare & Rehabilitation Center?
State health inspectors documented 53 deficiencies at SCOTTDALE HEALTHCARE & REHABILITATION CENTER during 2022 to 2024. These included: 53 with potential for harm. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates Scottdale Healthcare & Rehabilitation Center?
SCOTTDALE HEALTHCARE & REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by BONAMOUR HEALTH GROUP, a chain that manages multiple nursing homes. With 35 certified beds and approximately 27 residents (about 77% occupancy), it is a smaller facility located in SCOTTDALE, Pennsylvania.
How Does Scottdale Healthcare & Rehabilitation Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, SCOTTDALE HEALTHCARE & REHABILITATION CENTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (61%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Scottdale Healthcare & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's high staff turnover rate.
Is Scottdale Healthcare & Rehabilitation Center Safe?
Based on CMS inspection data, SCOTTDALE HEALTHCARE & REHABILITATION CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Scottdale Healthcare & Rehabilitation Center Stick Around?
Staff turnover at SCOTTDALE HEALTHCARE & REHABILITATION CENTER is high. At 61%, the facility is 15 percentage points above the Pennsylvania average of 46%. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Scottdale Healthcare & Rehabilitation Center Ever Fined?
SCOTTDALE HEALTHCARE & REHABILITATION CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Scottdale Healthcare & Rehabilitation Center on Any Federal Watch List?
SCOTTDALE HEALTHCARE & 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.