SOMERSET HEALTHCARE & REHABILITATION CENTER
For profit - Limited Liability company
120 Beds
ABRAHAM SMILOW
Data: November 2025
Trust Grade
43/100
#494 of 653 in PA
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Somerset Healthcare & Rehabilitation Center has a Trust Grade of D, indicating below-average quality with some significant concerns. They rank #494 out of 653 facilities in Pennsylvania, placing them in the bottom half, and #4 out of 6 in Somerset County, meaning only one local option is rated higher. The facility is showing improvement; the number of issues decreased from 27 in 2024 to 19 in 2025. Staffing is relatively stable, with a turnover rate of 34%, lower than the state average of 46%, but the overall staffing rating is just 2 out of 5 stars. However, the facility has faced notable issues, including a serious incident where a resident was injured due to unsafe transfer techniques, resulting in a hip fracture. Additionally, residents have reported that food is often served cold, failing to meet safety and quality standards. While the facility does have a strong quality measure rating of 5 out of 5 stars, these weaknesses in care practices raise valid concerns for families considering this nursing home.
- Trust Score
- D
- In Pennsylvania
- #494/653
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ○ Average
- 34% turnover. Near Pennsylvania's 48% average. Typical for the industry.
- Penalties ✓ Good
- $13,156 in fines. Lower than most Pennsylvania facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 37 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 66 deficiencies on record. Higher than average. Multiple issues found across inspections.
43/100
Bottom 25%
Needs review
27 → 19 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 27 issues
2025: 19 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (34%)
14 points below Pennsylvania average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Pennsylvania average (3.0)
Below average - review inspection findings carefully
Staff Turnover: 34%
11pts below Pennsylvania avg (46%)
Typical for the industry
Federal Fines: $13,156
Below median ($33,413)
Minor penalties assessed
Chain: ABRAHAM SMILOW
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 66 deficiencies on record
1 actual harm
Mar 2025
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for ...
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Based on review of policies and clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to ensure that call bells were within reach for one of 37 residents reviewed (Resident 8).
Findings include:
The facility's policy for call lights: accessibility and response, dated February 24, 2025, indicated that the purpose was to ensure the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility, to allow residents to call for assistance. Staff will ensure the call light is within reach of residents and secured, as needed.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 8, dated February 18, 2025, revealed that the resident had moderate cognitive impairment, required assistance from staff for care needs, and had diagnoses that included right-sided hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) following a stroke.
A care plan for Resident 8, dated March 7, 2025, indicated that the resident was at risk for falls and that staff were to be sure the resident's call light was within reach and encourage the resident to use it. A care plan, dated November 20, 2024, indicated that the resident required assistance with activities of daily living, and that staff were to encourage the resident to use his call bell to call for assistance.
Observations of Resident 8 in his room on March 10, 2025, at 11:05 a.m. revealed that the resident was lying in his bed and his call bell was not seen on or near his bed. The resident was asked how he would call for help if he needed it, and he shrugged his shoulders.
Interview with Licensed Practical Nurse 1 on March 10, 2025, at 11:05 a.m. confirmed that Resident 8 did not have his call bell within reach and should have.
Interview with the Director of Nursing on March 10, 2025, at 12:48 p.m. confirmed that Resident 8's call bell should have been within his reach.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
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 observations, as well as interviews with staff, it was determined that the facility fai...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies and observations, as well as interviews with staff, it was determined that the facility failed to maintain the confidentiality of medical information for one of 37 residents reviewed (Resident 54).
Findings include:
The facility's policy regarding confidentiality and medical records, dated February 24, 2024, indicated that employees are to ensure computer screens with health information are minimized or closed to ensure resident confidentiality.
Observations on March 12, 2025, at 8:00 a.m. revealed a laptop on top of a medication cart in the hallway outside of room [ROOM NUMBER] that was open and the Medication Administration Record (MAR) for Resident 54 was visible to staff, residents, and visitors in the hallway. No nurse was observed near the medication cart.
Interview with Registered Nurse 2 on March 12, 2025, at 8:06 a.m. revealed that she had walked away from the medication cart for a few minutes to get something she needed and did not minimize the laptop screen, allowing Resident 54's confidential medical information to be visible to anyone passing by and that she should have minimized her screen.
Interview with the Nursing Home Administrator on March 12, 2025, at 11:09 a.m. confirmed that laptop screens with confidential medical information should not be unattended or viewable by unauthorized people.
28 Pa. Code 201.29(a) Resident Rights.
28 Pa. Code 211.5(b) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for thre...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to notify the resident and legal guardian in writing regarding the reason for hospitalization for three of 37 residents reviewed (Residents 27, 49, 71).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated January 17, 2025, indicated that the resident was understood, could understand others, and was cognitively intact.
A nursing note, dated October 20, 2024, at 3:28 p.m., revealed that the Certified Registered Nurse Practitioner (CRNP) was notified of the resident's laboratory test results showing an elevated white blood cell count and the resident's continued complaint of abdominal pain, nausea, and chills. Orders were received to transfer the resident to the hospital for evaluation and treatment.
Interview with the Assistant Director of Nursing on March 11, 2025, at 12:41 p.m. confirmed that there was no documented evidence that a written notice of Resident 27's transfer to the hospital was provided to the resident's representative regarding the reason for transfer to the hospital on October 20, 2024.
A quarterly MDS assessment for Resident 49, dated February 1, 2025, indicated that the resident was cognitively impaired, required assistance with daily care needs, and had diagnoses that included dementia.
A nurse's note for Resident 49, dated January 5, 2025, at 4:41 p.m., revealed that results of an x-ray were provided to the facility, which indicated that the resident had a left hip fracture, and orders were obtained to send the resident to the hospital for follow up care.
There was no documented evidence that a written notice of Resident 49's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer.
Interview with the Director of Nursing on March 11, 2025, at 1:36 p.m. confirmed that there was no documented evidence that a written notice of Resident 49's transfer to the hospital was provided to the resident's representative regarding the reason for transfer to the hospital on January 1, 2025.
An annual MDS assessment for Resident 71, dated February 3, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included hypertension (high blood pressure), diabetes, and Chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause airflow obstruction and breathing difficulties).
Nursing notes for Resident 71, dated February 19, 2025, at 9:15 a.m., revealed that the resident was lethargic (feeling tired, sluggish, or lacking in energy) and hard to arouse. Pulse oximeter (an electronic device that measures the saturation of oxygen carried in your red blood cells) on oxygen at two liters per minute via nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was 84 percent (a normal pulse oximeter reading for your oxygen saturation level is between 95 and 100 percent). Certified Registered Nurse Practitioner (CRNP - are RNs with additional education and training that allows them to work under a wider scope of practice) was in and examined the resident. The resident was placed on oxygen at four liters per minute via face mask and still unable to raise the resident's oxygen level. Orders were received to send the resident to emergency department for further evaluation and treatment. A nursing note at 9:50 a.m. revealed that the resident was sent to the emergency department via ambulance.
There was no documented evidence that a written notice of Resident 71's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer.
Interview with the Nursing Home Administrator on March 13, 2025, at 3:18 p.m. confirmed that there was no documented evidence that a written notice of Resident 71's transfer to the hospital was provided to the resident and/or the resident's responsible party regarding the reason for transfer.
28 Pa. Code 201.25 Discharge Policy.
28 Pa. Code 201.29(f)(g) Resident Rights.
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 facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to issue a bed-hold notice at the time of an anticipated leave of abs...
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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 issue a bed-hold notice at the time of an anticipated leave of absence from the facility for one of 37 residents reviewed (Resident 71).
Findings include:
The facility's policy regarding bed hold notices and transfer, dated February 24, 2025, indicated that in the event of an emergency transfer of a resident, the facility will provide written notice of the facility's bed-hold policies to the resident and/or the resident's representative within 24 hours. The facility will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The facility will keep a signed and dated copy of the bed-hold notice information given to the resident and/or resident's representative in the resident's file and/or medical record. The facility will provide this written information to all facility residents, regardless of their payment source.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 71, dated February 3, 2025, revealed that the resident was understood, could understand others, and had diagnoses that included hypertension (high blood pressure), diabetes, and chronic obstructive pulmonary disease (COPD - a group of lung diseases that cause airflow obstruction and breathing difficulties).
Nursing notes for Resident 71, dated February 19, 2025, at 9:15 a.m., revealed that the resident was lethargic (feeling tired, sluggish, or lacking in energy) and hard to arouse. Pulse oximeter (an electronic device that measures the saturation of oxygen carried in your red blood cells) on oxygen at two liters per minute via nasal cannula (a device that delivers extra oxygen through a tube and into your nose) was 84 percent (a normal pulse oximeter reading for your oxygen saturation level is between 95 and 100 percent). Certified Registered Nurse Practitioner (CRNP - are RNs with additional education and training that allows them to work under a wider scope of practice) was in and examined the resident. The resident was placed on oxygen at four liters per minute via face mask and still unable to raise the resident's oxygen level. Orders were received to send the resident to emergency department for further evaluation and treatment. A nursing note at 9:50 a.m. revealed that the resident was sent to the emergency department via ambulance.
There was no documented evidence that a bed-hold notice was issued to Resident 71 or her responsible party at the time of her transfer to the hospital.
Interview with the Nursing Home Administrator on March 13, 2025, at 3:18 p.m. confirmed that there was no documented evidence that a bed-hold notice was issued to Resident 71 or her responsible party at the time of her transfer to the hospital.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(b)(3) Management.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
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 comprehensive significa...
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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 comprehensive significant change Minimum Data Set assessments were completed in the required time frame for one of 37 residents reviewed (Resident 65).
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) was to be no later than the 14th calendar day after determination that a significant change in the resident's status occurred (determination date + 14 calendar days) and the significant change comprehensive MDS assessment was to be completed no later than the 14th calendar day after determination that significant a change in the resident's status occurred (determination date + 14 calendar days).
A care plan for Resident 65, dated July 24, 2024, revealed that the resident required hospice care (medical care to help someone with a terminal illness) related to an end-stage illness.
Physician's orders for Resident 65, dated July 23, 2024, included an order for the resident to be admitted to hospice.
There was no documented evidence that a significant change in status MDS assessment was completed for Resident 65 after being admitted to hospice care on July 23, 2024.
Interview with the Nursing Home Administrator on March 11, 2025, at 2:57 p.m. confirmed that the significant change comprehensive MDS assessment for Resident 65 was not completed within the required time frame.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for seven of 37 residents reviewed (Residents 9, 23, 36, 39, 49, 55, 57).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that Section N0415I1 (Antiplatelet Medications - medications used to reduce the risk of blood clots) was to be checked if the resident received an anti-platelet medication during the seven-day assessment period.
Physician's orders for Resident 9, dated January 7, 2021, included an order for the resident to receive 81 milligrams (mg) of aspirin daily. The resident's Medication Administration Record (MAR) for February 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 9, dated February 1, 2025, revealed that Section N0415I1 was coded zero (0), indicating that the resident did not receive an anti-platelet during the last seven days.
An interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on March 13, 2025, at 2:45 p.m. confirmed that Resident 9's MDS assessment was not coded accurately.
Physician's orders for Resident 23, dated February 25, 2024, included an order for the resident to receive 81 mg of aspirin daily. The resident's MAR for January 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, an annual MDS assessment for Resident 23, dated January 10, 2025, revealed that Section N0415I1 was coded zero (0), indicating that the resident did not receive an anti-platelet during the last seven days.
An interview with Nursing Home Administrator on March 11, 2025, at 2:57 p.m. confirmed that the MDS assessment for Resident 23 was coded incorrectly.
Physician's orders for Resident 36, dated September 10, 2022, included an order for the resident to receive 81 mg of aspirin daily. Review of the resident's MAR for January 2025 and February 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 36, dated February 1, 2025, revealed that Section N0415I was coded (0) indicating that the resident did not receive an anti-platelet during the last seven days.
An interview with the RNAC on March 13, 2025, at 2:44 p.m. confirmed that Resident 36's MDS assessment dated [DATE], was coded incorrectly.
Physician's orders for Resident 49, dated January 9, 2025, included an order for the resident to receive 81 mg of aspirin daily. Review of the resident's MAR for January 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 49, dated February 1, 2025, revealed that Section N0415I was not coded (1) is taking, indicating that the resident did not receive an anti-platelet during the last seven days.
An interview with the RNAC on March 13, 2025, at 2:47 p.m. confirmed that Resident 49's MDS assessment dated [DATE], was not coded accurately.
The RAI User's Manual, dated October 2024, indicated that Section O0110J1 (Dialysis) was to be checked if the resident received peritoneal or renal dialysis at the nursing home or at another facility during the 14-day assessment period.
Physician's orders for Resident 39, dated February 15, 2025, included an order for the resident to have hemodialysis every Tuesday, Thursday, and Saturday. The resident's dialysis communication form, dated February 25, 2025, revealed that the resident received hemodialysis. However, a quarterly MDS assessment for Resident 39, dated February 28, 2025, revealed that Section O0110J1b was coded zero (0), indicating that the resident did not receive dialysis during the last 14 days while a resident.
An interview with the RNAC on March 13, 2025, at 2:44 p.m. confirmed that Resident 39's MDS assessment was coded incorrectly.
The Long-Term Care Facility RAI User's Manual, dated October 2024, indicated that the purpose of Section J0100B (Received as needed pain medication?) was to identify if the resident received any as needed pain medication during the seven-day look-back period.
Review of the MAR for Resident 55, dated February, 2025, revealed that the resident did not receive as needed pain medication during the seven-day look-back period. However, a quarterly MDS assessment for Resident 55, dated February 13, 2025, revealed that Section J0100B was coded (yes), indicating that the resident did receive as needed pain medication during the seven-day look-back period.
An interview with the RNAC on March 13, 2025, at 2:46 p.m. confirmed that Resident 55's MDS assessment dated [DATE], was coded incorrectly.
The Long-Term Care Facility RAI User's Manual, dated October 2024, indicated that Section N0451K was to be coded (1) is taking, if the resident received an anti-convulsant during the seven-day assessment period.
Physician's orders for Resident 57, dated November 21, 2023, included an order for the resident to receive three 125 mg capsules of gabapentin (anticonvulsant medication) three times a day. Review of the MAR for Resident 57, dated February 2025, revealed that staff administered three 125 mg capsules of gabapentin three times a day during the seven-day look-back period. However, a quarterly MDS assessment for Resident 57, dated February 24, 2025, revealed that Section N0415K was coded (0), indicating that the resident did not receive an anti-convulsant medication during the seven-day assessment.
Interview with the Director of Nursing on March 12, 2025, at 12:30 p.m. confirmed that Resident 57's MDS assessment dated [DATE], was coded incorrectly.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of facility policies 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 ...
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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 a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 37 residents reviewed (Residents 8, 55).
Findings include:
A facility policy for care plan revision upon status change, dated February 24, 2025, indicated that the comprehensive care plan will be reviewed and revised as necessary when the resident experiences a status change. The care plan will be updated with new or modified interventions.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 8, dated February 18, 2025, revealed that the resident had moderate cognitive impairment, required assistance from staff for care needs, and had diagnoses that included right-sided hemiplegia (loss of strength in the arm, leg, and sometimes face on one side of the body) following a stroke.
Care plan for Resident 8, dated March 7, 2025, included that the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs. Staff were to apply bilateral TED (thrombo-embolic deterrent) hose (medical compression stockings designed to prevent blood clots) in the morning and remove in the evening and apply a right-hand thumb splint (immobilizes the thumb to support and protect it) daily. There was no documented evidence that the TED hose or right-hand thumb splint were being applied.
Observations of Resident 8 on March 11, 2025, at 11:39 a.m. revealed the resident was not wearing TED hose or a right-hand thumb splint.
Interview with the Director of Nursing on March 11, 2025, at 1:22 p.m. revealed that the TED hose and right-hand thumb hand splint were discontinued, and that Resident 8's care plan should have been revised to reflect that; however, it was not.
A quarterly MDS assessment for Resident 55, dated February 13, 2025, revealed that the resident was cognitively intact, required assistance from staff for care needs, and had diagnoses that included Spina Bifida (a birth defect where the spinal cord does not close completely) with hydrocephalus (a buildup of fluid in and around the brain).
Care plan for Resident 55, dated April 14, 2022, indicated that the resident was receiving an anticoagulant (medication used to prevent and treat blood clots). A care plan, dated August 11, 2022, indicated that the resident was receiving and an antidepressant (medication that can help treat depression). There was no documented evidence that the resident was receiving anticoagulant or antidepressant medication.
Interview with the Nursing Home Administrator on March 13, 2025, at 3:27 p.m. revealed that Resident 55 was not receiving anticoagulant or antidepressant medication, and that his care plan should have been revised to reflect that, and it was not.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0661
(Tag F0661)
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 a discharge summary, including a recapitulation of the resident's stay, was completed f...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a discharge summary, including a recapitulation of the resident's stay, was completed for one of one discharged residents reviewed (Resident 70).
Findings include:
Physician's orders for Resident 70, dated January 4, 2025, included an order for the resident to be discharged home with the services of Home Health including physical therapy, occupational therapy, and nursing.
A nursing note for Resident 70, dated January 4, 2025, revealed that the resident was discharged from the facility at 11:15 a.m. to home with all of his possessions.
As of March 13, 2025, there was no documented evidence that a discharge summary that included a recapitulation of the resident's stay was completed for Resident 70.
Interview with the Assistant Director of Nursing on March 13, 2025, at 3:18 p.m. confirmed that there was no documented evidence that a discharge summary was completed for Resident 70.
28 Pa. Code 211.5(d) Clinical Records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for medication administration for one of 3...
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Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to follow physician's orders for medication administration for one of 37 resident (Resident 27) and failed to follow physician's orders related to bowel protocols for two of 37 residents reviewed (Residents 9, 60).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 27, dated January 17, 2025, revealed that the resident was cognitively intact and had diagnoses that included septicemia (a life-threatening condition where bacteria or other microorganisms enter the bloodstream and cause a systemic infection).
Physician's orders for Resident 27, dated January 10, 2025, included orders for the resident to receive 100 milligrams (mg) of Doxycycline every 12 hours for cellulitis (a common bacterial infection of the skin and underlying tissues) for 10 days. The resident's Medication Administration Record (MAR) for January 2025 revealed that the 9:00 p.m. dose of Doxycycline was not given on January 10, 2025, due to waiting for the delivery from the pharmacy. Doxycycline was administered at 9:00 a.m. on January 11 through January 20, 2025; however, there was no documented evidence that the course of Doxycycline was extended to complete the administration every 12 hours for 10 days as ordered.
Physician's orders for Resident 27, dated January 10, 2025, included orders for the resident to receive 5 grams of Erythromycin ointment in her left eye at bedtime for blepharitis (an inflammation of the eyelids, typically affecting the edges where the eyelashes grow) for 10 days. The resident's MAR for January 2025 revealed that the 9:00 p.m. dose of Erythromycin was not given on January 10, 2025, due to waiting for the delivery from the pharmacy and Erythromycin was administered at 9:00 a.m. on January 11 through January 19, 2025 (nine days). There was no documented evidence that the course of Erythromycin was extended to complete the administration at bedtime for 10 days as ordered.
Physician's orders for Resident 27, dated February 19, 2025, included orders for the resident to receive 5 grams of Erythromycin ointment in her right eye twice a day for bacterial conjunctivitis (an inflammation of the conjunctiva, the clear membrane that covers the white part of the eye and lines the inside of the eyelids) for seven days. The resident's MAR for February 2025 revealed that the 9:00 p.m. dose of Erythromycin was not given at 9:00 p.m. on January 10, 2025, due to waiting for the delivery from the pharmacy and Erythromycin was administered at 9:00 a.m. on January 11 through January 26, 2025. There was no documented evidence that the course of Erythromycin was extended to complete the administration twice a day for seven days as ordered.
Interview with the Assistant Director of Nursing on March 11, 2025, at 12:41 p.m. confirmed that the first dose of the resident's orders for antibiotics mentioned on the above dates were not administered, and the order was not extended to complete the full ordered duration.
A facility policy for the bowel protocol, dated February 24, 2025, indicated that all shifts are to record bowel elimination times, amount, and consistency of stool on appropriate documentation tool. If the record indicates that the resident did not have a bowel movement for three days, Milk of Magnesia will be administered on the three-to-eleven shift. If the resident does not have a bowel movement by morning, the eleven-to-seven shift will administer a suppository as ordered by the physician. If this protocol is not effective, the three-to-eleven shift will administer an enema as ordered by the physician. Document interventions and results in the nurses' notes and Medication Administration Records.
Physician's orders for Resident 9, dated January 16, 2021, and December 31, 2024, included orders for staff to administer 30 milliliters (ml's) of Milk of Magnesia (MOM - an oral laxative) every 72 hours as needed for constipation or no bowel movement in three days, a 10 milligram (mg) Bisacodyl suppository (a laxative inserted rectally) every 96 hours as needed for constipation if MOM was not effective - to be given the morning of the fourth day, and a Fleets enema (a liquid inserted rectally to stimulate a bowel movement) rectally every 96 hours as needed for constipation or if there was no result from the suppository- to be given at bedtime on the fourth day.
Resident 9's bowel movement records for January and February 2025 revealed that the resident did not have a bowel movement January 13 through 17 (five days), February 4 through 9 (six days), February 12 through 17 (six days), and February 19 through 23, 2025 (five days). The MARs for February and March 2025 revealed no documented evidence that staff administered any of the bowel protocol medications to Resident 60 between February 24, 2025, and March 5, 2025 (10 days). However, there was no documented evidence in the clinical record that the physician's orders for bowel protocol were initiated.
Interview with the Director of Nursing on March 13, 2025, at 3:20 p.m. confirmed that bowel protocol was not followed for Resident 9 on the above-mentioned dates and should have been.
A quarterly MDS assessment for Resident 60, dated February 1, 2025, indicated that the resident was cognitively intact, was dependent on staff for daily care needs, and had diagnoses that included diabetes and paraplegia (loss of muscle function in the lower half of the body, including both legs).
Physician's orders for Resident 60, dated January 6, 2025, included orders for staff to administer 30 milliliters (ml's) of Milk of Magnesia (MOM - an oral laxative) every 72 hours as needed for constipation or no bowel movement in three days, a 10 milligram (mg) Biscolax suppository (a laxative inserted rectally) every 96 hours as needed for constipation or no results from the MOM, and a Fleets enema (a liquid inserted rectally to stimulate a bowel movement) every 96 hours as needed for constipation or if there was no result from the suppository.
Resident 60's bowel movement records for February and March 2025 revealed that the resident did not have a bowel movement on February 24 through March 6, 2025. The MARs for February and March 2025 revealed no documented evidence that staff administered any of the bowel protocol medications to Resident 60 between February 24, 2025, and March 5, 2025 (10 days).
A nurse's note for Resident 60, dated March 7, 2025, at 6:32 p.m. indicated that the resident had no bowel movement as indicated by the nurses for the past 10 days, even after treated with bowel protocol. A nurse's note dated March 8, 2025, at 8:13 a.m. revealed that abdominal x-ray results were obtained and the findings included a moderate colonic ileus (colon (large intestine) loses its ability to move food and waste properly) and moderate stool was noted in the colon. A nursing note, dated March 10, 2025, at 11:20 a.m. revealed that services were on site to complete an abdominal x-ray. A palliative care note, dated March 12, 2025, indicated that x-ray results revealed an increased colonic fecal accumulation and moderate to severe constipation and nonobstructive ileus pattern.
Interview with the Director of Nursing on March 12, 2025, at 3:36 p.m. confirmed that bowel protocol was not followed for Resident 60 on the above-mentioned dates.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that recommended pressure ulcer interventions were provided to preve...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that recommended pressure ulcer interventions were provided to prevent skin breakdown for one of 37 residents reviewed (Resident 56).
Findings include:
A facility policy regarding pressure injury prevention and management, dated February 24, 2025, revealed that the facility was to provide treatment and services to heal the pressure ulcer, prevent infection, and the development of additional pressure ulcers.
A quarterly Minimum Data assessment Set (MDS) (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated February 26, 2024, revealed that the resident had no speech, was rarely or never understood, was dependent on staff for all care areas, had diagnoses that included Alzheimer's disease and non traumatic brain dysfunction, and had one non-stageable pressure ulcer (unable to determine the depth of the wound) that was not present on admission.
A pressure ulcer investigation for Resident 56, dated December 9, 2024, revealed that there was deep tissue injury area on the left heel with interventions to provide education and encouragement for small frequent position changes and turning and repositioning.
Skin and wound practitioner notes for Resident 56, dated December 12, 19, 26, 2024; January 2, 9, 16, 23, 30, 2025; February 6, 13, 20, 27, 2025; and March 6, 2025, each recommended the preventative measure to turn and reposition the resident at least every two hours.
Physician's orders for Resident 56, dated December 10, 2024, included an order to cleanse the left heel with wound cleanser, then paint the wound with Betadine 10 percent (infection and promote healing pressure sores), and cover with an abdominal pad (an absorptive dressing) once a day and as needed.
Observations of Resident 56 on March 11, 2025, between 10:33 a.m. and 1:38 p.m. revealed that the resident remained midline in bed on his back with his legs bent and his knees leaning towards the door. There was a wedge cushion on the chair next to the resident's bed.
Interview with Nurse Aide 3 on March 11, 2025, at 1:38 p.m. revealed that Resident 56 was to be turned and repositioned every two hours. Staff would use pillows or the wedge cushion to turn and reposition him. Hospice comes in every morning Monday through Friday and they will position him, then staff will reposition him in the morning, and he is usually in his chair in the afternoons.
Interview with the Nursing Home Administrator on March 11, 2025, at 2:19 p.m. confirmed that Resident 56 should have been turned and repositioned and also revealed that the facility does not document turning and repositioning of residents as it is a nursing measure.
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
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label a multi-use vial of Aplisol in one of one medication rooms reviewed, and failed to secure medication in a medication cart.
Findings include:
The facility's policy regarding medication labeling and storage, dated February 24, 2025, indicated that multi-dose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer dated for the open vial. The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Compartments (including but not limited to drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use.
Current manufacturer's directions for Aplisol (tuberculin purified protein derivative) indicated that vials in use for more than 30 days should be discarded due to possible oxidation and degradation, which may affect potency.
Observations in the facility's A-wing medication room refrigerator on March 13, 2025, at 9:01 a.m. revealed one multi-use vial of Aplisol that was open and undated. Interview with Licenced Practical Nurse 4 at the time of the observation confirmed that the vial was not dated and should be discarded.
An interview with the Nursing Home Administrator on February 13, 2025, at 11:49 a.m. confirmed that the multi-use vial of Aplisol should have been dated when opened.
Observations on March 12, 2025, at 8:00 a.m. revealed an unlocked and unattended medication cart in the hallway outside of room [ROOM NUMBER].
Interview with Registered Nurse 3 on March 12, 2025, at 8:06 a.m. confirmed that she had walked away from the medication cart for a few minutes to get something and should have locked it but did not.
Interview with the Nursing Home Administrator on March 12, 2025, at 11:09 a.m. confirmed that medication carts should be locked when not in use.
28 Pa Code 211.9(a)(1) Pharmacy Services.
28 Pa Code 211.12(d)(1) Nursing 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 two residents reviewed (Resident 65) who received hospice care.
Findings include:
An agreement between the facility and a hospice provider (provider of end-of-life services), dated April 8, 2024, indicated that the hospice provider would provide the following information to the facility to facilitate coordination of care: a hospice election 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). The skilled nursing facility shall identify a skilled nursing facility designee within the skilled nursing facility and shall be responsible for obtaining the follow information from the hospice: the hospice election form.
A care plan for Resident 65, dated July 24, 2024, revealed that the resident required hospice care (medical care to help someone with a terminal illness) related to an end-stage illness.
Physician's orders for Resident 65, dated July 23, 2024, included an order for the resident to be admitted to hospice.
However, as of March 11, 2025, 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 election form from the hospice provider.
Interview with Registered Nurse 5 on March 11, 2025, at 2:09 p.m. confirmed that Resident 65's election benefit form was not in the resident's clinical record and/or in the hospice provider's clinical record. Registered Nurse 5 contacted the hospice provider and they faxed the resident's election benefit form to the facility today.
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 April 25, 2024; July 10, 2024; October 23, 2024; November 20, 2024; December 13, 2024; December 30, 2024; and January 22, 2025, 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 March 13, 2025, identified repeated deficiencies related to personal privacy and confidentiality of records, abuse and neglect policy, accuracy of assessments, comprehensive care plans, care plan revision, quality of care, treatment and prevention of pressure ulcers, accident hazards, dialysis, labeling and storage of drugs and biologicals, nutritive value, appearance, palatability and preferred temperature of food, and infection prevention and control.
The facility's plan of correction for a deficiency regarding a failure to provide personal privacy and confidentiality of records, cited during the surveys ending December 30, 2024, and March 13, 2025, 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 F583, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding personal privacy and confidentiality of records.
The facility's plan of correction for a deficiency regarding a failure to provide implementation of abuse and neglect policies, cited during the surveys ending April 25, 2024, and January 22, 2025, 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 F607, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the development and implementation of abuse and neglect policy.
The facility's plan of correction for a deficiency regarding a failure to provide accurate resident Minimum Data Set (MDS) assessments, cited during the surveys ending April 25, 2024; December 13, 2024; and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accuracy of MDS assessments.
The facility's plan of correction for a deficiency regarding a failure to provide comprehensive resident care plans, cited during the surveys ending October 23, 2024, and March 13, 2025, 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 comprehensive resident care plans.
The facility's plan of correction for a deficiency regarding a failure to provide revisions to resident care plans, cited during the surveys ending April 25, 2024; November 20, 2024; and March 13, 2025, 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 revisions to resident care plans.
The facility's plan of correction for a deficiency regarding a failure to provide quality of care, cited during the surveys ending April 25, 2024; October 23, 2024; December 13, 2024; and March 13, 2025, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding quality of care.
The facility's plan of correction for a deficiency regarding a failure to provide treatment and prevention of pressure ulcers, cited during the surveys ending November 20, 2024, and March 13, 2025, 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 F686, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the treatment and prevention of pressure ulcers.
The facility's plan of correction for a deficiency regarding accident hazards, cited during the surveys ending July 10, 2024, and November 20, 2024, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding accident hazards.
The facility's plan of correction for a deficiency regarding a failure to provide dialysis services, cited during the surveys ending April 25, 2024, and March 13, 2025, 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 F698, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding dialysis.
The facility's plan of correction for a deficiency regarding a failure to label and store drugs and biologicals, cited during the surveys ending December 30, 2024, and March 13, 2025, 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 F761, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding labeling and storage of drugs and biologicals.
The facility's plan of correction for a deficiency regarding a failure provide food of the nutritive value, appearance, preferred temperatures and palatability cited during the surveys ending April 25, 2024, and March 13, 2025, 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 F804, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding the nutritive value, appearance, preferred temperature and palatability of foods.
The facility's plan of correction for a deficiency regarding a failure provide infection control and prevention practices cited during the surveys ending April 25, 2024; December 13, 2024; and March 13, 2025, 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 F880, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding infection control and prevention
Refer to F583, F607, F641, F656, F657, F684, F686, F689, F698, F761, F804, and 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 policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to mainta...
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Based on review of established infection control guidelines, facility policies, and clinical records, as well as observations and staff interviews, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of 37 residents reviewed (Residents 56).
Findings include:
CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (MDRO) transmission was 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 February 24, 2025, indicated that EBP are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. EBPs were necessary when performing high contact resident care. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room EBP's are indicated for residents with wound care. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 56, dated February 26, 2024, revealed that the resident had no speech and was rarely or never understood, was dependent on staff for all care, had a diagnoses that included Alzheimer's disease, non-traumatic brain dysfunction, and had one non-stageable pressure ulcer (unable to determine the depth of the wound) that was not present on admission. A care plan, dated December 9, 2024, revealed that Resident 56 had an unstageable pressure ulcer to his left heel related to immobility. A care plan, dated February 11, 2025, revealed that the resident was on EBP related to the area on the left heel.
Physician's orders for Resident 56, dated February 11, 2025, included an order for the resident to be on EBPs for the pressure area to the left heel.
Observations of Resident 56's wound care to his left heel and left great toe on March 11, 2025, at 10:49 a.m. revealed that Licensed Practical Nurse 6 washed her hands and donned clean gloves; however, she did not don a gown. She then performed the wound treatment to the resident's left heel.
Interview with Licensed Practical Nurse 6 on March 11, 2025, at 10:59 a.m. confirmed that she did not don a gown prior to performing Resident 56's wound treatment. She indicated that she did not think that she need to wear any other PPE for the dressing change.
Interview with the Infection Control Preventionist on March 11, 2025, at 3:14 p.m. confirmed that Licensed Practical Nurse 6 should have donned a gown prior to performing Resident 56's wound treatment.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
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 develop and implement a comprehensive person-centered care plan for each re...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included specific and individualized interventions for three of 37 residents reviewed (Residents 38, 57, 60).
Findings include:
A facility policy for comprehensive care plans, dated February 24, 2025, included that the facility will develop and implement a person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychological needs and all services that are identified in the resident's comprehensive assessment and meet professional standards of quality. The comprehensive care plan will be developed within seven days after the completion of the comprehensive MDA assessment.
CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP's) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. CMS updated its infection prevention and control guidance effective April 1, 2024. The recommendations now include the use of EBP's during high-contact care activities for residents with chronic wounds or indwelling medical devices, regardless of their MDRO status, in addition to residents who have an infection or colonization with a CDC-targeted or other epidemiologically important MDRO when contact precautions do not apply.
The facility's policy regarding EBP, dated February 24, 2025, indicated that EBP are used as an infection prevention and control intervention to reduce the spread of MDROs to residents. EBPs were necessary when performing high-contact resident care. Gloves and gown are applied prior to performing the high-contact resident-care activity (as opposed to before entering the room). EBP's are indicated for residents with wound care. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.
A quarterly Minimum Data assessment Set (MDS) (a mandated assessment of a resident's abilities and care needs) for Resident 38, dated January 8, 2025, revealed that the resident could usually make himself understood, was cognitively intact, and received nutrition through a feeding tube. Physician's orders, dated January 8, 2025, included orders for the resident to be on EBP every shift due to having a feeding tube, and physician's orders, dated January 28, 2025, included orders for the resident to receive continuous feedings of Jevity 1.2 (a tube feeding formula that contains 1.2 calories in every milliliter) at 65 cubic centimeters (cc's) per hour.
Observations of Resident 38 on March 11, 2025, at 1:04 p.m. revealed that the resident was in bed and his tube feeding of Jevity 1.2 was running at 65 cc/hr, and there was an EBP sign on his closet door.
Review of Resident 38's current care plan revealed no documented evidence that a care plan was developed to address the resident's care needs related to EBP.
Interview with the Assistant Director of Nursing on March 11, 2025, at 12:41 p.m. confirmed that there was no care plan developed to address the resident's need for EBP.
A quarterly MDS assessment for Resident 57, dated February 24, 2024, indicated that the resident was cognitively intact, was independent with personal hygiene care needs, and had diagnoses that included anoxic brain damage (an acquired brain injury that occurs when the brain is deprived of oxygen).
Physician's orders for Resident 57, dated November 11, 2024, included an order that the resident may go out to smoke. However, there was no documented evidence that a care plan regarding Resident 57's smoking was developed until March 10, 2025.
Interview with the Assistant Director of Nursing on March 12, 2025, at 12:25 p.m. revealed that a care plan for smoking was not developed until March 10, 2025, and it should have been developed in November 2024 when Resident 57 was identified as a smoker.
A quarterly MDS assessment for Resident 60, dated February 1, 2025, indicated that the resident was cognitively intact, was dependent on staff for daily care needs, and had diagnosis that included diabetes and paraplegia (loss of muscle function in the lower half of the body, including both legs).
Physician's orders for Resident 60, dated January 6, 2025, included an order that the resident have his percutaneous endoscopic gastrostomy (PEG) tube (a medical device inserted through the abdominal wall directly into the stomach) checked for placement every shift.
Interview with the Director of Nursing on March 12, 2025, at 3:36 p.m. revealed that as of March 11, 2025, a care plan for the care and treatment of Resident 60's PEG tube was not developed.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that interventions to prevent weight loss were provided as recommended by the dietician for ...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that interventions to prevent weight loss were provided as recommended by the dietician for one of 37 residents reviewed (Resident 46).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated August 8, 2024, revealed that the resident had moderate cognitive impairment, required set up and clean up assistance with eating, had diagnoses that included left hemiplegia (loss of strength in the arm, leg, and sometimes the face on one side of the body) following a stroke, and had unplanned weight loss.
A care plan for Resident 46, dated August 8, 2024, indicated that the resident had the potential for a nutritional problem and that a registered dietician was to evaluate and make diet change recommendations as needed, and Med Pass supplement (a fortified nutritional shake that provides additional calories and protein) was to be provided as ordered.
A Nutritional Review assessment for Resident 46, dated February 9, 2025, indicated that Resident 46 was to continue receiving 60 milliliters (ml) of Med Pass three times a day to provide 720 kilocalories and 30 grams of protein which will help meet the deficit from sporadic meal intakes.
Review of the Medication Administration Record (MAR) for Resident 46, dated February 2025 and March 2025, revealed no documented evidence that the resident was provided the Med Pass supplement between February 10, 2025, and March 11, 2025.
Review of the weight record for Resident 46 revealed that on February 4, 2025, the resident weighed 177.8 pounds (lbs) and on March 4, 2025, the resident's weight was 162.4 lbs.
Interview with the Assistant Director of Nursing on March 11, 2025, at 3:44 p.m. revealed that a Med Pass supplement order was originally entered to be given for one month and was completed on February 9, 2025; however, the Med Pass supplement should have been re-ordered per the dietician's recommendation and was not.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to complete treatments as ordered by the physician for one of 37 residents reviewed (Resident 48) who ...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to complete treatments as ordered by the physician for one of 37 residents reviewed (Resident 48) who received dialysis services.
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 48, dated February 9, 2025, revealed that the resident understood and understands, was cognitively intact, received dialysis, and had diagnoses that included end-stage renal disease. A care plan, dated February 4, 2025, revealed that the resident received peritoneal dialysis (a treatment for kidney failure that uses the lining of your abdomen, or belly, to filter your blood inside your body), and staff were to check and change the dressing at the access site daily. Physician's orders for Resident 48, dated February 3, 2025, and February 13, 2025, respectively, included orders for the resident to have 0.1 percent Gentamicin ointment applied to the peritoneal dialysis site topically every day shift and to receive peritoneal dialysis every night shift.
Resident 48's Treatment Administration Record (TAR's) for February and March 2025 revealed no documented evidence that Gentamicin was applied to the peritoneal dialysis site on February 4, 5, 7, 10, 13, 14, 18, 19, 22, and March 1, 3, 4, 11, and 12, 2025.
Interview with the Director of Nursing on March 13, 2025, at 12:31 p.m. confirmed that there was no documented evidence that staff completed the treatment of Gentamicin as ordered on the dates mentioned above.
28 Pa. Code 211.12(d)(3)(5) Nursing Services.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.
Findings inc...
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Based on review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at appetizing temperatures.
Findings include:
The facility's policy regarding food quality and palatability, dated February 24, 2025, indicated that food would be palatable, attractive, and served at a safe and appetizing temperature. Food was to be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimize the risk for scalding and burning.
Food Committee meeting minutes, dated February 5 and March 7, 2025, revealed that residents complained that food was not served at the proper temperature and the food was cold.
Interview with Resident 6, during the initial tour on March 10, 2025, at 11:49 a.m. revealed that meals were usually served cold. Resident 6 was alert and oriented, able to make her needs known, and usually eats in her room.
Interview with Resident 14 on March 10, 2025, at 10:31 a.m. revealed that he will eat his meals in his room and in the main dining room and at times they are served food that is not hot enough.
Interview with Resident 84 on March 10, 2025, at 10:48 a.m. revealed that she eats her meals in her room, and at times they were not served hot enough and that her meals arrived with food being cold. She stated that her waffles this morning were cold and slimy.
Observations in the main kitchen on March 11, 2024, revealed that the food cart for C-wing left the main kitchen at 12:03 p.m. and arrived on the C-wing at 12:04 p.m. Trays were passed to the residents in their rooms and the last resident was served at 12:15 p.m. At 12:15 p.m. the temperature of the crusted pork was 126.3 degrees Fahrenheit (F) and the peas were 127.7 degrees F. The pork and peas were lukewarm and not served at an appetizing temperature.
Interview with the Dietary Manager March 11, 2025, at 12:48 p.m. confirmed that she was aware that residents were complaining about food temperatures and was also aware of the policy regarding food that is to be served at appetizing temperatures.
28 Pa. Code 211.6(b) Dietary Services.
Jan 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 Nurse Aide Registry verification upon hire for two of two newly h...
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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 Nurse Aide Registry verification upon hire for two of two newly hired nurse aides reviewed (Nurse Aides 1 and 2), failed to ensure that nursing licenses were checked with the Pennsylvania State Board of Nursing for three of three newly hired nurses (Licensed Practical Nurse 1, Registered Nurse 1 and 2) and failed to complete a criminal background check for four of five newly hired nursing staff reviewed (Nurse Aide 1, Licensed Practical Nurse 1, Registered Nurse 1 and 2).
Findings include:
The facility's abuse policy, dated March 19, 2024, indicated that the facility will provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Background, reference and credential checks shall be conducted on all potential employees.
The personnel file for Nurse Aide 1 revealed that she was hired on November 26, 2024, and as of January 22, 2025, (two months after hire) registry verification with the Pennsylvania State Nurse Aide Registry and a criminal background check had not been completed.
The personnel file for Nurse Aide 2 revealed that she was hired on December 10, 2024, and as of January 22, 2025, (one month after hire) registry verification with the Pennsylvania State Nurse Aide Registry had not been completed.
The personnel file for Licensed Practical Nurse 1 revealed that she was hired on December 13, 2024, and as of January 22, 2025, (one month after hire) a licensure verification with the Pennsylvania State Board of Nursing and a criminal background check had not been completed.
The personnel file for Registered Nurse 1 revealed that she was hired on November 2, 2024, and as of January 22, 2025, (two months after hire) a licensure verification with the Pennsylvania State Board of Nursing and a criminal background check had not been completed.
The personnel file for Registered Nurse 2 revealed that she was hired on December 11, 2024, and as of January 22, 2025, (one month after hire) a licensure verification with the Pennsylvania State Board of Nursing and a criminal background check had not been completed.
Interview with the Nursing Home Administrator on January 22, 2025, at 3:10 p.m. confirmed that there was no documented evidence to indicate that registry verification with the Pennsylvania State Nurse Aide Registry, licensure verification with the Pennsylvania State Board of Nursing, and criminal background checks were completed prior to dates of hire for the above mentioned nusing staff and there should have been.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
Dec 2024
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medica...
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Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to provide confidentiality of residents' personal health information during medication administration for one of nine residents reviewed (Resident 2).
Findings include:
The facility policy regarding electronic health records, dated March 19, 2024, indicated that the resident's health information needs to remain private.
Observations on December 30, 2024, at 9:05 a.m. revealed that Licensed Practical Nurse 1 was not near her medication cart. Resident 2's personal health information was visible on the computer screen, which was facing the hallway.
Interview with Licensed Practical Nurse 1 on December 30, 2024, at 9:11 a.m. confirmed that she should have covered the resident's personal information when leaving the medication cart by securing the computer screen.
Interview with the Director of Nursing on December 30, 2024, at 12:31 p.m. confirmed that the computer screen with Resident 2's personal health information should have been covered when the nurse was not attending the medication cart.
28 Pa. Code 211.5(b) 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
Deficiency F0761
(Tag F0761)
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 medications were stored in a secure m...
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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 medications were stored in a secure manner for two of three medication carts reviewed (A unit long hall cart and C unit cart).
Findings include:
The facility's policy on administering medications, dated March 19, 2024, indicated that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by.
Observations on December 30, 2024, at 8:54 a.m. revealed that the medication cart for A unit long hall was in the hallway, against the wall, unlocked and unattended. A medication cup containing various medications was stored on top of the medication cart. Interview with Licensed Practical Nurse 2 on December 30, 2024, at 8:57 a.m. indicated that she was called away by a nurse aide and confirmed that the medication cart should have been locked when unattended and confirmed that the medication cup containing various medications should not have been left unattended on top of the cart.
Interview with the Director of Nursing on December 30, 2024, at 12:37 p.m. confirmed that the medication cart for A unit long hall should have been locked when unattended and confirmed that the medication cup containing various medications should not have been left unattended on top of the cart.
Observations on December 30, 2024, at 9:05 a.m. revealed that the medication cart for C Unit was unlocked. Interview with Licensed Practical Nurse 1 at 9:11 a.m. revealed that she went to care for a resident and during that time the cart was unattended.
Interview with the Director of Nursing on December 30, 2024, at 12:31 p.m. confirmed that the medication cart on the C Unit should have been secured when staff were not present.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
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
Deficiency F0806
(Tag F0806)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to honor food preferences for one of nine residents reviewed ...
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Based on review of clinical records, as well as observations and resident and staff interviews, it was determined that the facility failed to honor food preferences for one of nine residents reviewed (Resident 5).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated December 7, 2024, indicated that the resident was cognitively intact, was clearly understood and able to clearly understand others, and was independent with care needs.
An interview with Resident 5 on December 30, 2024, at 9:19 a.m. revealed that she was no longer able to get yogurt and a banana for breakfast. She indicated that she gets too many eggs and does not like eggs, and that prior to the new owners taking over, she was able to get yogurt and a banana for breakfast daily.
Interview with the Dietary Manager on December 30, 2024, at 12:01 p.m. revealed that she was not permitted to purchase yogurt and bananas when the new owners took over. She indicated that if Resident 5 wanted these items, the family would have to bring them in and store them in the resident's refrigerator on the unit.
Interview with the Dietary Manager on December 30, 2024, at 1:54 p.m. revealed that her boss indicated that they would provide yogurt and bananas for nutritional intervention if needed, but not necessarily for preference.
Interview with the Dietary Manager on December 30, 2024, at 2:12 p.m. revealed that Resident 5's preferences for a banana and yogurt were listed on her special request list, but the banana was removed and replaced with canned fruit when bananas were made unavailable. She revealed that there was no food replacement for the yogurt that she was no longer permitted to get; however, she did indicate that she was given permission this day to order a case of yogurt and bananas.
28 Pa. Code 211.6(b) Dietary Services.
28 Pa. Code 201.18(b)(1) Management.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected 1 resident
Based on a review of facility policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that the residents were provided with nightl...
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Based on a review of facility policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to ensure that the residents were provided with nightly snacks in accordance with their preferences for seven of nine residents reviewed (Residents 1, 2, 3, 4, 5, 7, 8).
Findings include:
A facility policy on snack serving dated, March 19, 2024, revealed that snacks will be provided to residents between meals, per resident's request, and at nighttime.
A review of resident council meeting minutes for November and December 2024 revealed that residents stated they were not being provided with evening snacks and would like to be.
A Quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 25, 2024, indicated that the resident was cognitively intact, understood, was understood by others, was independent for eating, and had diagnoses that included hemiparesis (a medical condition where there is weakness or paralysis on one side of the body).
Review of Resident 1's clinical record for November and December 2024 revealed that the resident was not provided with an evening snack on November 8, 2024, and December 17, and 27, 2024.
A Quarterly MDS assessment for Resident 2, dated December 2, 2024, indicated that the resident was cognitively intact, understood and was understood by others, was independent for eating, and had diagnoses that diabetes.
Review of Resident 2's clinical record for November and December 2024 revealed that the resident was not provided with an evening snack on November 2, 11, 16, 19, 21, 25, 2024, and December 1, 5, 6, 12, 23, and 25, 2024.
Interview with Resident 2 on December 30, 2024, at 8:54 a.m. revealed that she does not get a snack every evening and would prefer to have one.
A quarterly MDS assessment for Resident 3, dated November 2, 2024, indicated that the resident was cognitively intact, was understood and was able to understand others, was independent for eating, and had a diagnosis of diabetes.
Review of Resident 3's clinical record for November and December 2024 revealed that the resident was not provided with an evening snack on November 6, 8, and 20, 2024, and December 14 and 20, 2024.
Interview with Resident 3 on December 30, 2024, at 10:09 a.m. revealed that it's 50/50 when it comes to getting snacks and that they are not offered all the time.
An annual MDS assessment for Resident 4, dated November 19, 2024, indicated that the resident was cognitively intact, was understood and was able to understand others, and was independent for eating.
Review of Resident 4's clinical record for November and December 2024 revealed that the resident was not provided with an evening snack on November 6 and 8, 2024, and December 20, 2024.
A quarterly MDS assessment for Resident 5, dated December 7, 2024, indicated that the resident was cognitively intact, was clearly understood and able to clearly understand others, and was independent for eating.
Review of Resident 5's clinical record for November and December 2024 revealed that the resident was not provided with an evening snack on November 6, 8 and 20, 2024, and December 20, 2024.
Interview with Resident 5 on December 30, 2024, at 9:19 a.m. revealed that snacks are rarely passed, and there are minimal snacks available.
An admission MDS assessment for Resident 7, dated November 7, 2024, indicated that the resident was cognitively impaired, sometimes understands and is sometimes understood, and was dependent on staff for eating.
Review of Resident 7's clinical record for November and December 2024 revealed that the resident was not provided with an evening snack on November 9, 11, 15, 19, 21, 26, 27, 30, 2024, and December 5, 7, 16, 17, 21, 25, 26, 30, and 31, 2024.
A quarterly MDS assessment for Resident 8, dated November 13, 2024, indicated that the resident was cognitively intact, was clearly understood and able to clearly understand others, was independent for eating, and had diagnoses that included diabetes and protein calorie malnutrition.
Review of Resident 8's clinical record for November and December 2024 revealed that the resident was not provided with an evening snack for the entire month of November 2024, and December 20 and 27, 2024.
Interview with Resident 8 on December 30, 2024, at 11:33 a.m. revealed that he gets snacks but not every day.
Interview with Director of Nursing on December 30, 2024, at 12:50 p.m. confirmed that residents were requesting evening snacks and were not getting them. She indicated that snacks should be provided when asked and offered nightly.
28 Pa. Code 201.29(i) Resident Rights.
Dec 2024
4 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
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Min...
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Based on review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for two of 11 residents reviewed (Residents 2, 10).
Findings include:
The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, revealed that Sections H0100 through H0300 were to gather information on the use of bowel and bladder appliances and urinary and bowel continence. Section H0300 was to be coded nine (9), not rated if during the seven-day look-back period the resident had an indwelling bladder catheter (a tube held in the bladder to drain urine), or other types of catheters or no urine output for the entire seven days. Section H0400 (Bowel Continence) was to be coded zero (0) if the resident was always continent, coded one (1) if the resident was occasionally incontinent, coded two (2) if the resident was frequently incontinent, coded three (3) if the resident was always incontinent, and coded nine (9), not rated if during the seven-day look-back period the resident had an ostomy or did not have a bowel movement for the entire seven days.
A quarterly MDS assessment for Resident 2, dated October 30, 2024, revealed that Section H0100A was checked, indicating that the resident had an indwelling urinary catheter; however, Section H0300 was coded with a three (3), indicating that the resident was always incontinent of urine, and Section H0400 was coded with a nine (9), indicating that bowel continence that it was not rated.
Interview with the Assistant Director of Nursing on December 12, 2024, at 4:08 p.m. confirmed that Resident 2 had an indwelling urinary catheter during the assessment period in October 2024, and that Section H0300 should have been coded with a nine (9) and not a zero (0) and that Section H0400 should not have been coded with a nine (9).
The RAI User's Manual, dated October 2024, revealed that Section O0250A influenza (flu) was to be coded with a zero (0) (No) if the resident did not receive the influenza vaccination in this facility for this year's influenza vaccination season, and coded one (1) (Yes) if the resident did receive the influenza vaccination in this facility for this year's influenza vaccination season.
A quarterly MDS assessment for Resident 2, dated October 30, 2024, revealed that Section O0250A was coded with a one (1), indicating that the resident did receive the influenza vaccination in this facility for this year's influenza vaccination season. However, review of Resident 2's clinical record revealed that the resident did not receive the influenza vaccination for this year's influenza vaccination season.
Interview with the Assistant Director of Nursing on December 12, 2024, at 4:08 p.m. confirmed that Resident 2 did not receive the influenza vaccination for this year's influenza vaccination season, and that Section O0250A of the quarterly MDS assessment of October 30, 2024, should have been coded with a zero (0) because the resident did not receive this year's influenza vaccination for the current influenza vaccination season.
The RAI User's Manual, dated October 2024, revealed that Section O0250A influenza (flu) was to be coded with a zero (0) (No) if the resident did not receive the influenza vaccination in this facility for this year's influenza vaccination season, and coded one (1) (Yes) if the resident did receive the influenza vaccination in this facility for this year's influenza vaccination season. Section O0250C, reason for not receiving the influenza vaccination, was to be coded with a one (1) indicating that the resident was not in this facility during this year's influenza vaccination season, a two (2) indicating that the resident received the vaccine outside of this facility, a three (3) indicating that the resident was not eligible to receive the vaccine due to medical contraindication, a four (4) indicating that the resident was offered and declined the vaccine, a five (5) indicating that the vaccine was not offered, a six (6) indicating the inability to obtain the influenza vaccine due to a declared shortage, and a nine (9) indicating none of the above.
A quarterly MDS assessment for Resident 10, dated November 3, 2024, revealed that Section O0250A was coded with a zero (0) indicating that the resident did not receive the influenza vaccination in this facility for this year's influenza vaccination season. Section O0250C was coded with a five (5) indicating that the vaccine was not offered. However, review of Resident 10's clinical record revealed that the resident was offered the influenza vaccination and declined that vaccine.
Interview with the Assistant Director of Nursing/Infection Preventionist on December 12, 2024, at 4:15 p.m. confirmed that Resident 10 was offered the influenza vaccination for this year's influenza vaccination season, and that Section O0250C of the quarterly MDS assessment, dated November 3, 2024, should have been coded with a four (4) indicating that the resident was offered and declined the vaccine.
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
Deficiency F0779
(Tag F0779)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's clinical record contained signed and dated reports of radiolo...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident's clinical record contained signed and dated reports of radiologic and other diagnostic services for one of 11 residents reviewed (Resident 2).
Findings include:
Physician's orders for Resident 2, dated June 20, 2024, included an order for the resident to have an ultrasound (an imaging test that uses sound waves to make pictures of organs, tissues, and other structures inside your body) of her bilateral breasts as a screening for any abnormal lumps/masses.
However, review of Resident 2's clinical record revealed no documented evidence of a signed and dated ultrasound report for the resident that was ordered on June 20, 2024.
Interview with the Assistant Director of Nursing on December 12, 2024, at 4:08 p.m. indicated that Resident 2 had the ultrasound completed and confirmed that there was no documented evidence of a signed and dated ultrasound report in the resident's clinical record.
28 Pa. Code 211.5(f) Clinical Records.
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
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on review facility policies, established infection control guidelines, and residents' clinical records, as well as observations and staff and resident interviews, it was determined that the faci...
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Based on review facility policies, established infection control guidelines, and residents' clinical records, as well as observations and staff and resident 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 11 residents reviewed (Residents 3, 7).
Findings include:
CDC guidance on Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (MDRO) transmission was 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.
A facility policy related to Enhanced Barrier Precautions, dated February 1, 2024, indicated that EBP are indicated for residents with an infection or colonization with a CDC-targeted MDRO when contact precautions do not apply or with chronic wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO.
An admission nursing note for Resident 3, dated December 4, 2024, at 5:30 p.m. indicated that the resident arrived at the facility via ambulance and had a suprapubic catheter (a flexible tube that drains urine from the bladder through the abdomen). A physician's order for Resident 3, dated December 10, 2024, revealed that the resident had a suprapubic catheter for neurogenic bladder (bladder lacks control due to nerve or muscle problems).
Observations of Resident 3 on December 12, 2024, at 5:22 p.m. revealed that the resident had no signage at the entrance to her room or in her room to indicate infection control measures for EBP were in place related to her suprapubic catheter. Interview with Resident 3 at the time of the observation revealed that when the staff change her suprapubic catheter and empty her catheter bag, they do not wear gowns.
Interview with the Assistant Director of Nursing/Infection Preventionist on December 12, 2024, at 5:35 p.m. confirmed that Resident 3 was not currently on EBP and should have been related to her suprapubic catheter.
A nursing note, dated December 2, 2024, at 5:45 p.m., revealed that the resident was alert and oriented, had a fall from a bench resulting in a fractured cervical vertebrae, and had a peritoneal dialysis catheter (a thin, flexible tube surgically implanted into the abdomen (peritoneum) to facilitate peritoneal dialysis, a treatment for kidney failure) located on her left abdomen. A physcian's order, dated December 3, 2024, included an order for peritoneal dialysis (a treatment for kidney failure that uses the lining of the abdomen to filter blood and remove waste and excess fluid) independently every day shift from 8:00 a.m. to 12:00 p.m.
Observations of Resident 7 on December 12, 2024, at 5:17 p.m. revealed that the resident had no signage at the entrance to her room or in her room to indicate infection control measures for EBP were in place related to his chronic wounds.
Interview with the Assistant Director of Nursing/Infection Preventionist on December 12, 2024, at 5:35 p.m. confirmed that Resident 7 was not currently on EBP and should have been related to her peritoneal dialysis catheter.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and staff interviews, it was determined that the facility failed to monitor intake and output for one of 11 residents reviewed (Resident 3) who had an indwelling urina...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to monitor intake and output for one of 11 residents reviewed (Resident 3) who had an indwelling urinary catheter and failed to follow physician's orders related to bowel protocols for one of 11 residents reviewed (Resident 6).
Findings include:
An admission nursing note for Resident 3, dated December 4, 2024, at 5:30 p.m. indicated that the resident arrived at the facility via ambulance and had a suprapubic catheter (a flexible tube that drains urine from the bladder through the abdomen). A physician's order for Resident 3, dated December 10, 2024, revealed that the resident had a suprapubic catheter for neurogenic bladder (bladder lacks control due to nerve or muscle problems). A care plan for Resident 3, dated December 6, 2024, revealed that the resident had a suprapubic catheter in place for neurogenic bladder and the facility was to monitor and document intake and output as per facility policy.
Review of Resident 3's Medication Administration Record, Treatment Administration Record, and clinical records revealed no documented evidence that the facility measured and recorded the resident's intake and output as per the care plan.
Interview with the Director of Nursing on December 12, 2024, at 4:42 p.m. confirmed that there was no documented evidence in Resident 3's clinical record that the facility measured and recorded the resident's intake and output as per the care plan.
An admission MDS assessment for Resident 6, dated November 22, 2024, revealed that the resident was cognitively impaired, was frequently incontinent of bowel, and had diagnoses that included dementia.
Physician's orders for Resident 6, dated November 15, 2024, included orders for staff to administer 30 milliliters (ml's) of Milk of Magnesia (MOM - an oral laxative) every 72 hours as needed for constipation or no bowel movement in three days, a 10 milligram (mg) Biscolax suppository (a laxative inserted rectally) every 96 hours as needed for constipation or no results from the MOM, and a Fleets enema (a liquid inserted rectally to stimulate a bowel movement) every 96 hours as needed for constipation or if there was no result from the suppository.
Resident 6's bowel movement records for November and December 2024 revealed that the resident did not have a bowel movement from November 25 to 29, 2024, (five days) and December 2 to 9, 2024 (eight days). The resident's Medication Administration Records (MAR's) for November and December 2024 revealed no documented evidence that staff administered any of the bowel protocol medications to Resident 6 during the above time period.
Interview with the Assistant Director of Nursing on December 12, 2024, at 4:08 p.m. confirmed that Resident 6's physician's orders for bowel medications were not followed.
28 Pa. Code 211.12(d)(5) Nursing Services.
Nov 2024
3 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on review of fire safety plans, clinical records, and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were ...
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Based on review of fire safety plans, clinical records, and investigative reports, as well as staff interviews, it was determined that the facility failed to ensure that safe transfer techniques were used in accordance with their care plans and emergency evacuation plans for one of seven residents reviewed (Resident 1) who required the use of a mechanical lift for transfers, resulting in a left hip fracture.
Findings include:
The facility's current Fire Response Plan revealed for emergency removal of a resident from bed when working alone revealed that staff were to slip both arms under the resident's body and pull the resident towards the edge of the bed then drop to their knee nearest the head. Staff were to pull the lower half of the resident's body from the bed so that the extended knee supported the resident's hips. Staff were to use both arms to lower the resident's upper body to the floor, let the resident's legs slide gently to the blanket, and pull the resident from the room head first.
The facility's current Emergency Evacuation Plan revealed that residents in immediate danger were to be evacuated to a safe location. Staff were to use good judgement with the transfer of residents. Next staff were to continue to evacuate residents to their designated outside area. Nurse aides would assist in the evacuation of residents to designated outside evacuation areas for each wing, as directed. Staff were to use good judgement with the transfer of residents to the safest mode of transportation to evacuate the facility or area.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 3, 2024, revealed that the resident sometimes could make himself understood, sometimes could understand others, was cognitively impaired, and had diagnoses that included dementia and a stroke. The resident's care plan, revised April 21, 2021, revealed that he required a mechanical lift with the assistance of two staff for transfers.
A functional ability and goals form, completed by the Director of Rehabilitation, dated August 25, 2024, revealed that Resident 1 was dependent on staff for transfers from the chair/bed to chair and tub/shower.
A facility investigation, dated November 11, 2024, at 6:20 p.m., indicated that staff was attempting to transfer Resident 1 to his wheelchair during an active fire evacuation. They were unable to safely transfer him to his chair without more assistance, so he was lowered to the floor with two staff members present. A draw sheet was then placed under the resident and four persons transferred the resident from the floor to the chair. Resident 1 complained of pain on his left side at the time of the transfer. There were no injuries observed at the time of the incident.
A nursing note, dated November 12, 2024, at 12:42 a.m., revealed that Resident 1 complained of pain all over, especially to the lower back, left hip, and left leg. He yelled when the nurse touched his leg. New orders were received for x-rays of the lumbar spine, left hip, and left femur.
An x-ray report, dated November 12, 2024, revealed that the resident's left hip had an acute (recent) displaced (out of line) intertrochanteric (the upper part of the thigh bone) fracture.
A written statement by Licensed Practical Nurse 3, dated November 12, 2024, revealed that Nurse Aide 4 went in to transfer Resident 1 into his wheelchair. The resident had his legs out over the side of the bed and was lying back on the bed. Nurse Aide 4 asked her to help him transfer Resident 1 and she told him that she had to get gloves. In the meantime Nurse Aide 4 bear hugged Resident 1 to lift him up, he was dead weight, and his legs buckled under him. She told Nurse Aide 4 to lower the resident to the floor so he did not fall.
A written statement by Nurse Aide 4 on November 14, 2024, revealed that C wing began to fill up with smoke and they started to get residents out during the evacuation. He and a nurse picked up Resident 1 after they sat him up. When they tried to turn him to put the wheelchair under him, his legs gave out underneath him, so they laid him down on his back.
The facility's employee orientation checklist, dated September 5 2024, revealed that Nurse Aide 4 completed training regarding fire safety and evacuation procedures.
Interview with the Director of Rehabilitation on November 19, 2024, at 12:20 p.m. revealed that Resident 1 always required a mechanical lift for transfers and that transferring the resident out of bed with a one assist, stand and pivot, during the fire drill was not appropriate.
Interview with Licensed Practical Nurse 3 on November 19, 2024, at 12:36 p.m. revealed that Nurse Aide 4 came to the door and asked for help to transfer Resident 1. The resident's legs were off the bed and he was lying flat on the bed, and she told him give her a minute. Nurse Aide 4 then bear hugged Resident 1, and she could see the resident was going down. She could not help lift Resident 1, since he was dead weight, and she told Nurse Aide 4 to lower Resident 1 to the floor and she would get help. She confirmed that Nurse Aide 4 lifted Resident 1 and when he turned to put the resident in his chair, she could see the resident going down. She confirmed that Resident 1 was a mechanical lift and always was a lift, and Nurse Aide 4 bear hugged Resident 1 and tried to transfer him by himself.
Interview with Nurse Aide 4 on November 19, 2024, at 4:33 p.m. confirmed that he did bear hug Resident 1 to get him up and into his wheelchair. He reported that Licensed Practical Nurse 3 did not physically help to stand him, but tried to get the wheelchair under the resident, but when he could not get the resident into the chair, she then told him to lay the resident down. He stated that he was aware that Resident 1 was a mechanical lift.
Interview with the Director of Nursing on November 19, 2024, at 2:46 p.m. confirmed that Nurse Aide 4 did not transfer Resident 1 out of bed with a mechanical lift due to a fire evacuation. She was not sure if the resident was a mechanical lift or could assist with transfers.
Interview with the Nursing Home Administrator on November 19, 2024, at 4:05 p.m. revealed that she was not aware that Nurse Aide 4 bear hugged Resident 1 and attempted to transfer him out of bed by himself.
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of clinical records and facility investigations, as well as staff interviews, it was determined that the facility failed to revise residents' care plans with individualized interventio...
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Based on review of clinical records and facility investigations, as well as 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 seven residents reviewed (Resident 1).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated November 3, 2024, revealed that the resident sometimes could make himself understood, sometimes could understand others, was cognitively impaired, and had diagnoses that included dementia and a stroke. The resident's care plan, dated April 21, 2021, revealed that he required a mechanical lift with the assistance of two staff for transfers.
A facility investigation, dated November 11, 2024, at 6:20 p.m., revealed that staff was attempting to transfer Resident 1 to his wheelchair during active fire evacuation. They were unable to safely transfer him to his chair without more assistance, so he was lowered to the floor with two staff members present. A draw sheet was then placed under the resident and four persons transferred the resident from the floor to the chair. Resident 1 complained of pain on his left side at the time of transfer. There were no injuries observed at the time of the incident.
A nursing note, dated November 12, 2024, at 12:42 a.m., revealed that Resident 1 complained of pain all over, especially to the lower back, left hip, and left leg. He yelled when the nurse touched his leg. New orders were received for x-rays of the lumbar spine, left hip, and left femur.
An x-ray report, dated November 12, 2024, revealed that the resident's left hip had an acute (recent) displaced (out of line) intertrochanteric (the upper part of the thigh bone) fracture.
The care plan for Resident 1, revised on November 13, 2024, indicated that the resident required one assist with transfers.
Interview with Nurse Aide 1 on November 19, 2024, at 1:21 p.m. confirmed that Resident 1 currently and always required a mechanical lift for transfers.
Interview with Nurse Aide 2 on November 19, 2024, at 1:25 p.m. confirmed that Resident 1 required a mechanical lift for transfers and was never a one assist for transfers as long as she could remember.
Interview with the Director of Rehabilitation on November 19, 2024, at 12:20 p.m. revealed that Resident 1 always required a mechanical lift for transfers, especially now with a current fracture.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected multiple residents
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were monitored for one of seven residents revie...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were monitored for one of seven residents reviewed (Resident 2).
Findings include:
The facility's policy regarding prevention of pressure injuries, dated March 19, 2024, revealed that the resident was to be assessed on admission for existing pressure injury risk factors, and repeat the assessment weekly and upon any changes.
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated October 20, 2024, revealed that the resident was understood, could understand others, and had one Stage 1 pressure injury (a mild pressure-related skin change that appears as a reddened area that does not turn white when pressed), as well as one unstageable pressure injury (a full-thickness tissue loss that is covered by a layer of dead tissue) that was present upon admission. The resident's care plan, dated October 15, 2024, indicated that the resident has a right lateral malleolus (the bony bump on the outside of the right ankle) pressure wound, as well as a potential risk for skin integrity issues due to decreased mobility and fragile skin. Staff was to document weekly, which was to include the measurement of each area of the skin breakdown's width, length, depth, type of tissue, and exudate (fluid that leaks out of blood vessels into nearby tissues) and any other notable changes or observations.
Physician's orders for Resident 2, dated October 14, 2024, included an order for staff to cleanse the resident's left heel wound with Normal Sterile Saline (NSS - a mixture of water and salt), then apply betadine gauze to the open area, and cover with foam dressing every shift and as needed for dislodgment/soilage.
A nursing note for Resident 2, dated October 14, 2024, revealed that the resident arrived to the facility from the hospital via stretcher. Dressings were intact to his left heel and his right Achilles area.
An admission assessment for Resident 2, dated October 14, 2024, revealed that the resident had a surgical incision dressing in place to his right outer ankle and a pressure area that was covered with a large adhesive foam dressing to his left heel. However, there was no documented evidence of any description and/or measurements of the pressure area to his left heel.
A Certified Registered Nurse Practitioner (CRNP - a registered nurse who has advanced education and clinical training in a health care specialty area) note for Resident 2, dated October 17, 2024, revealed that the resident was seen that day in follow up of weakness and pain. The right ankle/heel wound at site of the debridement (a medical procedure that removes damaged, dead, or infected tissue from a wound to help it heal) and the calcanectomy (a surgical procedure that removes part or all of the heel bone to treat conditions like chronic osteomyelitis or non-healing foot ulcers) was observed. There was no drainage and it appeared to be healing when compared to photos provided by the previous facility. The left heel was noted to have a small open area with minimal amount of serosanguinous drainage (a normal, thin, watery fluid that leaks from a wound or incision site and is a combination of blood and serum, the liquid part of blood).
A CRNP note for Resident 2, dated October 23, 2024, revealed that the resident was seen that day in follow up of weakness and pain. The right ankle/heel wound at site of the debridement and the calcanectomy was observed. There was no drainage and it appeared to be healing when compared to photos provided by the previous facility. The left heel is noted to have a small open area with minimal amount of serosanguinous drainage.
A Wound CRNP note for Resident 2, dated November 8, 2024, revealed that the resident had a wound to his left lateral foot, which was unstageable and measured four centimeters (cm) by four cm by 16 cm.
Resident 2's Treatment Administration Records (TARs) for October and November 2024 revealed that staff cleansed the resident's left heel wound with NSS, applied the betadine gauze to the open area, and covered with a foam dressing twice a day from October 15, 2024, through November 11, 2024.
However, there was no documented evidence that the pressure wound to Resident 2's left heel was measured weekly from admission and/or that the wound was assessed weekly after October 23, 2024, until November 8, 2024.
Interview with the Nursing Home Administrator on November 19, 2024, at 5:10 p.m. confirmed that there was no documented evidence that the pressure wound to Resident 2's left heel was measured weekly from admission and/or that the pressure wound was assessed weekly after October 23, 2024, until November 8, 2024.
28 Pa. Code 211.12(d)(5) Nursing Services.
Oct 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized ...
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Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for one of four residents reviewed (Resident 2).
Findings include:
The facility's policy regarding care plans, dated March 19, 2024, revealed that the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan includes measurable objectives and timeframes; describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and reflects currently recognized standards of practice for problem areas and conditions.
An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated July 18, 2024, revealed that the resident was understood, could usually understand others, and had a diagnosis which included Raynaud's syndrome (a condition that causes blood vessels to suddenly constrict, resulting in the fingers or toes turning white, blue, and then red) with gangrene (the death and decay of body tissues due to a lack of oxygen).
A nursing note for Resident 2, dated July 11, 2024, revealed that report was called from the hospital and that the fingertips to her right hand were discolored due to the Raynaud's syndrome with gangrene.
A Certified Registered Nurse Practitioner (CRNP - is a registered nurse who has advanced training and education in a specific area of healthcare) for Resident 2, dated July 12, 2024, revealed that the resident was seen for admission and plan of care. The resident's third and fifth fingers were noted to be gangrenous (relating to gangrene, a serious condition that occurs when tissue dies due to a lack of blood supply).
There was no documented evidence that a comprehensive care plan that included specific and individualized interventions was developed for Resident 2 regarding her Raynaud's syndrome with gangrene.
Interview with the Nursing Home Administrator and the Director of Nursing on October 23, 2024, at 2:29 p.m. confirmed that Resident 2 did not have a comprehensive care plan developed that included specific and individualized interventions regarding her Raynaud's syndrome with gangrene.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow recommendations from the hospital for a follow-up appointment and failed to follow p...
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Based on clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow recommendations from the hospital for a follow-up appointment and failed to follow physician's orders for one of four residents reviewed (Resident 2).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated July 18, 2024, revealed that the resident was understood, could usually understand others, and had a diagnosis which included Raynaud's syndrome (a condition that causes blood vessels to suddenly constrict, resulting in the fingers or toes turning white, blue, and then red) with gangrene (the death and decay of body tissues due to a lack of oxygen).
Hospital Discharge Instructions for Resident 2, dated July 11, 2024, revealed that the resident had a follow-up appointment scheduled on August 21, 2024, at 2:00 p.m. with the endocrinologist (a doctor who specializes in diagnosing and treating disorders of the endocrine system) for adrenal adenoma (a type of benign (non-cancerous) tumor that is located in an adrenal gland).
Physician's orders for Resident 2, dated July 11, 2024, included an order for the resident to follow-up on August 21, 2024, with the endocrinologist for post-hospital follow up for an adrenal adenoma.
Review of Resident 2's clinical record revealed no documented evidence that the resident went to the appointment and/or that the resident refused to go to the appointment.
A nursing note for Resident 2, dated July 11, 2024, revealed that report was called from the hospital and that the fingertips to her right hand were discolored due to the Raynaud's syndrome with gangrene.
A Certified Registered Nurse Practitioner (CRNP - is a registered nurse who has advanced training and education in a specific area of healthcare) for Resident 2, dated July 12, 2024, revealed that the resident was seen for admission and plan of care. The resident's third and fifth fingers were noted to be gangrenous (relating to gangrene, a serious condition that occurs when tissue dies due to a lack of blood supply).
Physician's orders for Resident 2, dated July 12, 2024, included an order to please make a follow-up appointment with vascular for gangrene to her left third and fifth fingers.
Review of Resident 2's clinical record revealed no documented evidence that the resident had the appointment scheduled and/or that the resident refused to have the appointment scheduled.
Physician's orders for Resident 2, dated July 31, 2024, included an order to please make a follow-up appointment with vascular as soon as possible related to Raynaud's syndrome with gangrene.
Review of Resident 2's clinical record revealed no documented evidence that the resident had the appointment scheduled and/or that the resident refused to have the appointment scheduled.
Interview with the Director of Nursing on October 23, 2024, at 12:35 p.m. revealed that Resident 2's appointment with the endocrinologist scheduled for August 21, 2024, was scheduled prior to her arrival at the facility, so the resident would follow up with that appointment after her discharge from the facility because she was not there for that reason, and the CRNP was not aware that the resident needed to see the plastic surgeon first when she ordered the vascular follow ups.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
Apr 2024
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on review of facility policy, clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident's respiratory status was proper...
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Based on review of facility policy, clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident's respiratory status was properly monitored for one of 36 residents reviewed (Resident 43).
Findings include:
The facility's policy regarding oxygen administration, dated March 19, 2024, indicated that the facility would verify the physician's order and review facility protocol for oxygen administration.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 43, dated February 25, 2024, revealed that the resident was understood and could understand, was independent with care needs, and was on oxygen therapy.
Physician's orders for Resident 43, dated August 25, 2023, included an order for the resident to receive oxygen at a flow rate of 4 liters per minute via nasal cannula (tubes placed in the nostrils to deliver oxygen) to keep the resident's oxygen saturation (the percentage of oxygen in the blood) greater than 88 percent every shift.
A care plan for Resident 43, dated August 25, 2023, indicated that the resident was to have oxygen administered continuously at four liters per minute to maintain an oxygen saturation (the percentage of oxygen in the blood) above 88 percent, with pulse oximeter (a machine that measures the saturation of oxygen in the blood) checks every shift.
A review of Resident 43's clinical record revealed no documented evidence that pulse oximetry checks were obtained every shift as ordered from August 25, 2023, until April 14, 2024, to determine if the resident needed supplemental oxygen.
An interview with the Director of Nursing on April 24, 2024, at 9:02 a.m. confirmed that pulse oximetry checks for Resident 43 were not obtained every shift as ordered from August 25, 2023, until April 14, 2024.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on review of policies, personnel files, and education records, as well as staff interviews, it was determined that the facility failed to implement its written abuse prevention policies by faili...
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Based on review of policies, personnel files, and education records, as well as staff interviews, it was determined that the facility failed to implement its written abuse prevention policies by failing to ensure that the status of nursing licenses were checked with the State Board of Nursing for three of three newly hired nurses reviewed (Registered Nurse 2, Registered Nurse 3, Licensed Practical Nurse 4), failed to complete a nurse aide registry verification for one of one nurse aides reviewed upon hire (Nurse Aide 5), failed to ensure that criminal background checks were completed prior to hire for one of five employee files reviewed (Nurse Aide 5), failed to ensure that reference checks were obtained prior to hire for four of five employee files reviewed (Registered Nurse 2, Registered Nurse 3, Licensed Practical Nurse 4, Nurse Aide 5), and failed to ensure that staff received annual abuse training for three of six staff reviewed (Registered Nurse 6, Licensed Practical Nurse 7, Licensed Practical Nurse 8).
Findings include:
The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated March 19, 2024, indicated that persons applying for employment with the facility will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. This includes but is not limited to: employment history, criminal background check, abuse check with appropriate licensing board and registries prior to hire; sworn disclosure statement prior to hire; license or registration verification prior to hire; documentation of status of any disciplinary actions from licensing or registration boards and other registries; and information from former employers. Employees of the facility will receive education and training on resident rights, resident abuse, and abuse reporting during orientation and annually thereafter. Additional education and training will be provided as deemed necessary.
The personnel file for Registered Nurse 2 revealed a hire date of March 4, 2024. However, there was no documented evidence until April 23, 2024, that her license was checked with the State Board, and there was no documented evidence that reference checks from previous or current employers were obtained prior to the employees' start date.
The personnel file for Registered Nurse 3 revealed a hire date of January 15, 2024. However, there was no documented evidence that her license was checked with the State Board prior to her working, and there was no documented evidence that reference checks from previous or current employers were obtained prior to the employees' start date.
The personnel file for Licensed Practical Nurse 4 revealed a hire date of January 12, 2024. However, there was no documented evidence until April 23, 2024, that her license was checked with the State Board, and there was no documented evidence that reference checks from previous or current employers were obtained prior to the employees' start date.
The personnel file for Nurse Aide 5 revealed a hire date of January 20, 2024. However, there was no documented evidence that the nurse aide's standing on the Pennsylvania Nurse Aide Registry was verified, there was no documented evidence that the nurse aide's criminal background check was completed prior to hire, and there was no documented evidence that reference checks from previous or current employers were obtained prior to the employees' start date.
Interview with the Human Resources/Scheduler on April 24, 2024, at 4:23 p.m. confirmed that there was no documented evidence that Registered Nurse 2 and Licensed Practical Nurse 4's licenses were checked with the State Board until April 23, 2024; no documented evidence that Registered Nurse 3's license was checked with the State Board prior to her working; no documented evidence that Nurse Aide 5's standing on the Pennsylvania Nurse Aide Registry was verified or that a criminal background check was completed prior to hire; and no documented evidence that reference checks from previous or current employers were obtained prior to the start date for Registered Nurse 2, Registered Nurse 3, Licensed Practical Nurse 4, and Nurse Aide 5.
Education records for Registered Nurse 6 revealed a hire date of February 27, 2020. However, there was no documented evidence that he received the facility's resident abuse and abuse reporting training during the time period of February 27, 2023, through February 27, 2024.
Education records for Licensed Practical Nurse 7 revealed a hire date of February 1, 2022. However, there was no documented evidence that she received the facility's resident abuse and abuse reporting training during the time period of February 1, 2023, through February 1, 2024.
Education records for Licensed Practical Nurse 8 revealed a hire date of April 12, 2021. However, there was no documented evidence that she received the facility's resident abuse and abuse reporting training during the time period of April 12, 2023, through April 12, 2024.
Interview with the Assistant Director of Nursing/Infection Control Preventionist on April 25, 2024, at 3:02 p.m. confirmed that there was no documented evidence that Registered Nurse 6, Licensed Practical Nurse 7, or Licensed Practical Nurse 8 received the facility's annual resident abuse and abuse reporting training.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Se...
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Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 36 residents reviewed (Residents 3, 14, 29, 35, 70).
Findings include:
The Long Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section N0415F (Antibiotic - medications) was to be checked if the resident was taking any medications by pharmalogical classification, not how it was used, during the last seven days, or since admission/entry or reentry if less than seven days.
Current physician's orders for Resident 3 included orders for the resident to receive 1 Gram of Methenamine Hippurate (antibiotic medication) two times a day.
Medication Administration Record's (MAR's) for Resident 3, dated February, 2024, revealed that the resident received antibiotic medications from February 1 to February 29, 2024. However, Section N0410F of Resident 3's admission MDS assessment, dated February 4, 2024, was coded to indicate that the resident did not receive antibiotic medications during the seven days of the assessment period (daily).
The RAI User's Manual, dated October 2023, revealed that if a resident used oxygen, then Section O0110C was to be checked if it applied.
Physician's orders for Resident 14, dated August 4, 2023, included an order for the resident to receive 2 liters of oxygen per minute every shift.
Review of Resident 14's MAR for March 2024 revealed that she received 2 liters of oxygen every shift from March 1 to 31, 2024. However, a quarterly MDS assessment, dated March 28, 2024, revealed that Section O0110C was not checked, indicating that the resident did not receive oxygen during the review period.
The RAI User's Manual, dated October 2023 revealed that Section N was to record the number of days during the last seven days (or since admission/entry or reentry if less than seven days) that specific types of medications were received by the resident. Section N0415F was to indicate how many days the resident received an antibiotic during the seven-day review period.
Physician's orders for Resident 29, dated April 2, 2024, included an order for the resident to receive one drop of (10000-0.1 units/milliliter) Polytrim ophthalmic solution in each eye four times a day for conjunctivitis (inflammation or infection of the outer membrane of the eyeball and the inner eyelid). Review of the resident's MAR for April 2024 revealed that she received the Polytrim daily from April 2 to 9, 2024. However, Section N0415F of Resident 29's quarterly MDS assessment, dated April 9, 2024, was coded to indicate that the resident did not receive antibiotic medications during the seven days of the assessment period.
The RAI User's Manual, dated October 2023, revealed that Section N0415J (Hypoglycemic Medications - medications that lower blood sugars) was to be checked if the resident was taking any medications by pharmalogical classification, not how it was used, during the last seven days, or since admission/entry or reentry if less than seven days.
Physician's orders for Resident 29, dated March 21, 2024, included orders for the resident to receive 500 milligrams (mg) of Metformin HCl (hypoglycemic medication) one time a day for diabetes, and the resident's MAR for April 2024 revealed that she received Metformin HCl daily from April 1 to 23, 2024. However, Section N0415J of Resident 29's quarterly MDS assessment, dated April 9, 2024, was coded to indicate that the resident did not receive hypoglycemic medications during the seven days of the assessment period.
The RAI User's Manual, dated October 2023, revealed that Section N was to record the number of days during the last seven days (or since admission/entry or reentry if less than seven days) that specific types of medications were received by the resident. Section N0450A was to indicate if the resident received antipsychotic medications on a routine or as needed basis. Section N0450B was to indicate if the resident had a gradual dose reduction (GDR) attempted. Section N0450C was to indicated the date of the last GDR.
A monthly record review by the consultant pharmacist for Resident 35, dated October 12, 2023, revealed that a GDR of Seroquel (antipsychotic medication) was recommended, and the physician agreed to decrease the dose from 50 milligrams (mg) twice a day to 25 mg in the evening.
Physician's orders for Resident 35, dated October 21, 2023, included orders for the resident to receive 25 (mg) of Seroquel one time a day for schizophrenia (serious mental illness that affects how a person thinks, feels, and behaves). However, Section N0450B of Resident 35's quarterly MDS assessment, dated March 17, 2024, was coded to indicate that the resident did not receive a GDR, and there was no date documented on section N0450C.
The RAI User's Manual, dated October 2023, revealed that Section A2105 (Discharge Status) was to be coded one (1) through thirteen (13) depending on the location of the resident's discharge. If the resident was discharged to home/community(private home/apt, board/care, assisted living, group home, transitional living, other residential care arrangements), then Section A2105 was to be coded one (1), and if the resident was discharged to a short-term general hospital (acute hospital), then Section A2105 was to be coded four (4).
A nursing note for Resident 70, dated February 2, 2024, at 12:51 p.m., revealed that the resident was discharged home with her son.
A discharge MDS assessment for Resident 70, dated February 2, 2024, revealed that Section A2105 was coded four (4), indicating that the resident was discharged to an acute care hospital.
Interview with the Registered Nurse Assessment Coordinator (RNAC - a registered nurse who is responsible for the completion of MDS assessments) on April 25, 2024, at 9:05 a.m and 2:10 p.m. confirmed that the assessments mentioned above were coded incorrectly.
28 Pa. Code 211.5(f) Clinical Records.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
Based on review of facility policy 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 th...
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Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for six of 36 residents reviewed (Residents 5, 10, 28, 41, 43, 55).
Findings include:
The facility's policy regarding care plans, dated March 19, 2024, indicated that the interdisciplinary team would review and update the care plan when there was a significant change in the resident's condition; when the desired outcome was not met; when the resident had been readmitted to the facility from a hospital stay; and at least quarterly in conjunction with the required quarterly MDS assessment.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated February 22, 2024, revealed that the resident was usually understood and could usually understand others. A care plan for the resident, dated November 19, 2023, revealed that the resident has impaired visual function related to the need to wear glasses. Staff was to remind the resident to wear his glasses when he was up and ensure the resident was wearing glasses, which are clean, free from scratches, and in good repair, as well as report any damage to the nurse/family.
Interview with Registered Nurse 2 on April 23, 2024, at 11:15 a.m. revealed that Resident 5 does not have glasses.
However, there was no documented evidence that Resident 5's care plan was updated/revised to reflect that the resident did not have glasses.
An admission MDS assessment for Resident 10, dated February 2, 2024, indicated that the resident was moderately cognitively impaired, had a feeding tube, used oxygen, and had diagnoses that included malnutrition and respiratory failure. Physician's orders for Resident 10, dated January 26 and February 12, 2024, included orders for the resident to receive 3 liters of oxygen every shift for hypoxia (low levels of oxygen) and to receive 300 cubic centimeters (cc's) of Jevity 1.5 (tube feeding) four times a day via a feeding tube (tube in the abdomen used to provide nutrition).
A review of Resident 10's Treatment Administration Record (TAR) for February 2024 revealed the resident's oxygen was discontinued on February 20, 2024. A nursing note, dated March 7, 2024, at 10:25 a.m. revealed that Resident 10's feeding tube was lying on the bedside table. When asked by staff if he pulled it out himself he stated yes and it's not going back in!.
Observations of Resident 10 on April 25, 2024, at 10:30 a.m. revealed the resident was lying in bed and did not have a feeding tube and was not using oxygen.
Resident 10's current care plan included interventions for a feeding tube and oxygen therapy.
An interview with the Director of Nursing on April 24, 2024, at 2:56 p.m. confirmed that Resident 10's care plan was not updated to reflect that the feeding tube and oxygen therapy were discontinued.
A quarterly MDS assessment for Resident 28, dated April 19, 2024, revealed that the resident was understood, and could understand others. A care plan for the resident, dated March 1, 2024, revealed that the resident has a pressure area to left gluteus (located in the buttocks) related to fragile skin.
A nursing note for Resident 28, dated March 8, 2024, revealed that the resident's wounds were reviewed at the meeting with the Interdisciplinary Team and that the Stage 1 pressure injury (superficial reddening of the skin) to left gluteus was resolved.
However, there was no documented evidence that Resident 28's care plan was updated/revised to reflect that the resident did not have a Stage 1 pressure injury to his left gluteus.
Interview with the Director of Nursing on April 24, 2024, at 2:56 p.m. confirmed that there was no documented evidence that Resident 28's care plan was updated/revised to reflect that the resident did not have a Stage 1 pressure injury to his left gluteus.
An admission MDS for Resident 41, dated March 21, 2024, revealed that the resident had cognitive deficits, was usually understood, could usually understand, required assistance with care needs, had a Stage 2 pressure ulcer (pressure wound with superficial skin loss) to the bilateral buttocks, an unstageable pressure ulcer (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) to the right heel, and was taking an anticoagulant. Review of current care plans revealed that Resident 41 had an open wound to his bilateral buttocks and that he was receiving an anticoagulant medication.
A skin and wound note for Resident 41, dated March 26, 2024, at 9:05 a.m., revealed that his Stage 2 pressure ulcer to his bilateral buttocks was resolved. A weekly wound note for Resident 41, dated March 29, 2024, at 10:49 a.m., revealed that his Stage 2 pressure ulcer to his bilateral buttocks was resolved.
There was no documented evidence that Resident 41's care plan was revised to reflect that the resident's Stage 2 pressure ulcer to his bilateral buttocks was resolved.
Review of Resident 41's clinical record revealed that there was no documented evidence that he was receiving anticoagulant therapy.
Interview with the Director of Nursing on April 25, 2024, at 3:20 p.m. confirmed that Resident 41's care plans were not revised to reflect that the Stage 2 pressure ulcer to his bilateral buttocks was resolved or that he was not on anticoagulation therapy.
A quarterly MDS assessment for Resident 43, dated February 25, 2024, revealed that the resident was cognitively intact, was understood and could understand, was independent with care needs, had moderate difficulty hearing, and used a hearing aid. A care plan for Resident 43, dated April 10, 2022, indicated that the resident had a communication problem related to hearing.
Interview with Resident 43 on April 22, 2024, at 12:07 p.m. revealed that he was hard of hearing and that his hearing aid was not working, but he had an appointment to get it checked very soon.
An Ear, Nose and Throat (ENT) consult, dated January 31, 2024, indicated that Resident 43 wears a hearing aide in his right ear, was deaf in the left ear, and had Meniere's disease (disorder that affects balance and hearing).
There was no documented evidence to indicate that Resident 43's care plan was updated to reflect the use of a hearing aid in the right ear or that he was deaf in the left ear.
Interview with the Director of Nursing on April 25, 2024, at 12:59 p.m. revealed that she could not confirm that Resident 43's care plan needed updated.
A quarterly MDS assessment for Resident 55, dated January 31, 2024, revealed that the resident was usually understood, could understand, and had a diagnosis of Cerebral Vascular Accident (CVA - commonly referred to as a stroke) with hemiplegia (paralysis on one side of the body).
A nursing note for Resident 55, dated January 22, 2024, revealed that the writer was called to the resident's room to assess the resident. It was reported by nursing staff that the resident spilled her breakfast tray on herself while she was eating in bed and that her coffee spilled down the left side of her back causing her skin to be reddened. The resident had a recent stroke and can feed herself but is adapting to only utilizing her right hand. Staff was to utilize a sippy cup for all liquids including coffee.
A safe swallowing strategy for Resident 55, dated January 26, 2024, revealed that the consistency of her food and drinks were to be minced meats and thin liquids; she was to use a two-handled spouted cup (sippy cup) per nurse discretion; sit fully upright; if able, receive Zofran (a medication to treat nausea) 30 minutes before the meal; take small mouthfuls/sips; alternate mouthfuls of food and drink; use a cup with a spout/straw for drinking; stop eating if there was ongoing coughing, choking, gurgly voice or pooling of food in the mouth; and be supervised during meals.
Observations of Resident 55 on April 23, 2024, at 12:42 p.m.; April 24, 2024, at 12:26 p.m.; and April 25, 2024, at 8:31 a.m. revealed that the resident had two sippy cups on her over-the-bed table that contained coffee and water.
Observations on April 24, 2024, at 12:20 p.m. revealed that Nurse Aide 9 took Resident 55 her lunch tray. She then came out of the resident's room and told other staff that she was going to the kitchen to get a sippy cup for the resident because there was none on her tray.
Interview with Nurse Aide 9 on April 25, 2024, at 8:34 a.m. revealed that she noticed that Resident 55 did not have a sippy cup on her breakfast tray, so she went to get one from the kitchen. She indicated that the resident had spilled coffee on herself in the past, and because of that, the intervention was put into place for the resident to have a sippy cup.
However, there was no documented evidence that Resident 55's care plan was updated/revised to reflect individualized intervention for a sippy cup after the incident.
Interview with the Director of Nursing on April 25, 2024, at 9:40 a.m. confirmed that the intervention after the incident was for Resident 55 to have a sippy cup.
28 Pa. Code 211.12(d)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected multiple residents
Based on review of the Pennsylvania Nurse Practice Act and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were c...
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Based on review of the Pennsylvania Nurse Practice Act and residents' clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders were clarified for two of 36 residents reviewed (Residents 14, 28).
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.
Physician's orders for Resident 14, dated July 21, 2023, included orders for the resident to have blood sugar checks one time a day on Monday, Wednesday and Friday, and to receive 24 units of 100 unit/milliters of Lantus Solostar Solution one time a day for diabetes. The medication was to be held if the resident's blood sugar was less than 100 milligrams/deciliter (mg/dL). A care plan, dated April 9, 2021, indicated that diabetic medications were to be administered as ordered by the physician.
Resident 14's Medications Administration Record (MAR) for February, March, and April 2024 revealed that the resident resident received Lantus daily and her blood sugar was checked every Monday, Wednesday, and Friday. There was no documented evidence that staff clarified the order with the physician to see if the resident's blood sugars should be checked on Tuesday, Thursday, Saturday and Sunday to determine if her blood sugar was below 100 mg/dL for the Lantus to be held.
Interview with the Director of Nursing on April 24, 2024, at 9:00 a.m. confirmed that the Lantus and blood sugar check orders should have been clarified with the physician.
A quarterly MDS assessment for Resident 28, dated April 19, 2024, revealed that the resident was understood, could understand others, and had a diagnosis which included a Stage 4 pressure ulcer (full-thickness tissue loss with exposed bone, tendon, or muscle) of the sacral region (the portion of your spine between your lower back and tailbone).
Physician's orders for Resident 28, dated November 17, 2022, included an order for staff to cleanse the sacral wound with normal sterile saline (NSS - a sterile solution used for the moistening of wound dressings and wound debridement), then apply betadine soaked Kerlix (a type of bandage), cover with an ABD pad (a gauze dressing that absorbs fluid from large or heavily draining wounds), secure with gentle tape every two days, and then off for two days. Then staff was to cleanse the sacral wound with NSS, apply acetic acid (an acid used for wound care) soaked Kerlix, cover with an ABD, and secure with gentle tape every two days and then off for two days.
Physician's orders for Resident 28, dated March 21, 2024, included an order for the resident to have a wound vac (a wound vacuum device that removes pressure over the area of the wound to help a wound heal) to his sacral wound at 125 millimeters of mercury (mmHg) (when wound vac becomes available). Staff were to continue rotating the dressings until the wound vac was available.
A nursing note for Resident 28, dated March 23, 2023, revealed that the wound vac was received and applied to the resident's sacral pressure ulcer per the wound clinic orders. Orders were received to apply the wound vac, change the wound vac dressings every Monday, Wednesday, Friday, and as needed; maintain the wound vac pressure at 125 mmHg continuously; check the pressure setting on the wound vac; and check for leaks every shift.
There was no documented evidence that Resident 28's physician was contacted to clarify orders for the wound vac to his sacral wound, or to clarify if the order to continue rotating the dressings until the wound vac was available should have been discontinued.
Interview with the Director of Nursing on April 24, 2024, at 2:25 p.m. confirmed that there was no documented evidence that Resident 28's physician was contacted to clarify orders for the wound vac to his sacral wound, or to clarify if the order to continue rotating the dressings until the wound vac was available should have been discontinued.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
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 review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow recommendations from a neurologist (a medical doctor w...
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Based on review of facility policy and clinical record reviews, as well as staff interviews, it was determined that the facility failed to follow recommendations from a neurologist (a medical doctor with specialized training in diagnosing, treating, and managing disorders of the brain and nervous system) for a follow-up appointment for one of 36 residents reviewed (Resident 5), and failed to follow physician's orders for three of 36 residents reviewed (Residents 29, 34, 43).
Findings include:
The facility's medication administration policy, dated March 19, 2024, indicated that procedures were in place to provide guidelines for the safe administration of medications, and staff were to verify that there was a physician's order for the medication.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated February 22, 2024, revealed that the resident was usually understood, could usually understand others, and had a diagnosis of Parkinson's disease.
A neurology consult for Resident 5, dated January 25, 2024, revealed that the resident was a follow up in three months.
A nursing note for Resident 5, dated January 25, 2024, revealed that the new orders recommended by the neurologist were confirmed by the resident's physician to follow up with neurology in three months. The resident's wife was notified.
A social services note for Resident 5, dated January 26, 2024, revealed that the interdisciplinary team met for a care plan review for the resident. The care plan meeting was held with resident's wife. The resident's wife noted that at his neurology appointment on January 25, 2024, he may be receiving a diagnosis of Parkinson's disease. Future needs and appointments were discussed; however, there was no documented evidence that Resident 5 was scheduled for a follow-up neurology appointment.
Interview with Resident 5's wife on April 24, 2024, at 3:30 p.m. revealed that he was to be at a neurology appointment today, and that she drove from home to the neurologist's office to be with him at the appointment; however, he never showed up.
Interview with Registered Nurse 2 on April 24, 2024, at 4:10 p.m. revealed that when a resident comes back from an outside appointment and there is a recommendation for the resident to follow up, they will place a physician's order for the follow up appointment, as well as place it in an appointment/transport book, so that the scheduler can schedule the appointment and make arrangements for transportation to the appointment. She confirmed that there were no orders in Resident 5's clinical record, and it was not in the appointment/transport book for the resident to follow up in three months with neurology.
Interview with the Scheduler on April 25, 2024, at 10:00 a.m. revealed that she was not made aware of a three-month follow-up appointment for Resident 5 and that she called the neurology office yesterday and was trying to reschedule it. She was told by the neurology office that the resident's wife made the appointment; however, the scheduler did not receive the appointment card or the physician's order for the follow-up appointment.
Physician's orders for Resident 29, dated December 22, 2023, included an order for the resident to receive a 2.5 mg of Midodrine HCl three times a day for orthostatic hypotension (form of low blood pressure that happens when standing up from sitting or lying down), and the medication was to be held if her systolic blood pressure (the top number of a blood pressure reading) was greater than 130 millimeters of mercury (mmHg).
Resident 29's Medication Administration Record (MAR) for January, February, March, and April 2024 revealed that the resident's systolic blood pressure was greater than 130 mmHg at 3:00 p.m. on January 3; at 5:00 p.m. on April 18; and at 9:00 p.m. on January 1, 5, 10, 14, 31, and February 2, 13, 16, 23, 26, 27, and March 7 and 18, 2024. However, there was no documented evidence that the resident's Midrodrine was held.
Interview with the Director of Nursing on April 25, 2024, at 1:00 p.m. revealed that she could not confirm that physician's orders for Resident 29's blood pressure medications were followed on the above dates/times.
An annual MDS assessment for Resident 34, dated February 29, 2024, revealed that the resident was cognitively impaired, was usually understood and usually understands, receives psychotropic medications, and had diagnoses that included schizophrenia (a serious mental disorder that affects how people interpret reality), anxiety and depression.
Physician's orders for Resident 34, dated June 23, 2023, included an order for the resident to receive Haldol Decanoate Solution one milliliter (ml) intramuscularly (medication delivery that delivers medication into the muscle) at bedtime every three weeks on Fridays.
Review of Resident 34's Medication Administration Record (MAR) for December 8, 2023, revealed no documented evidence that the Haldol was administered as ordered.
Interview with the Director of Nursing on April 25, 2024, at 3:20 p.m. confirmed that there was no documented evidence that Resident 34's Haldol was administered as ordered on December 8, 2023.
A facility policy regarding insulin administration, March 19, 2024, revealed that the type of insulin, dosage requirements, strength, and method of administration must be verified before administration to ensure that it corresponds with the order on the medication sheet and the physician's order.
A quarterly MDS assessment for Resident 43, dated February 25, 2024, revealed that the resident was cognitively intact, was understood and understands, independent with care needs, and had diagnoses that included diabetes (a disease that interferes with blood sugar control), and received insulin. A care plan for Resident 43, dated March 21, 2022, indicated that the resident had diabetes mellitus and was to have his medication administered as the physician ordered and follow the sliding scale as ordered.
Physician's orders for Resident 43, dated November 28, 2023, and discontinued on April 17, 2024, included an order for the resident to receive units of Lispro insulin subcutaneously (injected just under the skin) before meals per sliding scale. Resident 43 was to receive four units of Lispro for a blood sugar between 200-250 mg/dl, eight units for a blood sugar between 251-300 mg/dl, ten units for a blood sugar of 301-350 mg/dl, 12 units for a blood sugar of 351-400 mg/dl, and 14 units for a blood sugar of 401-450 mg/dl and to call the physician.
A review of the Medication Administration Records (MAR's) for Resident 43, dated December 2023 and February through April 2024, revealed that on December 14, 2023, at 11:30 a.m. the resident's blood sugar was 424 mg/dl; on February 4, 2024, at 7:30 a.m. the resident's blood sugar was 409 mg/dl; on February 5 2024, at 11:30 a.m. the resident's blood sugar was 450 mg/dl; on February 6, 2024, at 11:30 a.m. the resident's blood sugar was 430 mg/dl; on March 9, 2024, at 4:30 p.m. the resident's blood sugar was 408 mg/dl; on March 30, 2024, at 4:30 p.m. the resident's blood sugar was 424 mg/dl; April 1, 2024, at 11:30 a.m. the resident's blood sugar was 442 mg/dl; and April 12, 2024, at 4:30 p.m. the resident's blood sugar was 401 mg/dl. There was no documented evidence that the physician was notified of these elevated blood sugars as ordered.
Interview with the Director of Nursing on April 25, 2024, at 1:00 p.m. revealed that she was unable to confirm that the physician was not notified of Residents 43's elevated blood sugars mentioned above.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected multiple residents
Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for dialysis per facility pol...
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Based on clinical record reviews, as well as observations and staff interviews, it was determined that the facility failed to ensure that physician's orders were obtained for dialysis per facility policy for one of 36 residents reviewed (Resident 42).
Findings include:
The facility's policy regarding dialysis care, dated March 19, 2024, indicated that the facility would require an order from the resident's primary care physician for dialysis treatments.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 42, dated February 1, 2024, indicated that the resident was cognitively intact and required hemodialysis (a process of cleaning the blood of toxins and returning it into the body). A care plan for the resident, dated June 29, 2023, revealed that the resident required hemodialysis related to end-stage renal disease.
A nursing note for Resident 42, dated April 10, 2024, indicated that the dialysis center reported that the resident had cough and congestion, and that he coughed once or twice at dialysis.
A review of the clinical record for Resident 42 revealed no documented evidence that a physician's order was obtained for dialysis treatments, appointment locations, dates, or times.
Interview with the Director of Nursing on April 24, 2024, at 2:25 p.m. confirmed that there was no documented evidence that a physician's order was obtained for Resident 42's dialysis treatments, and there should have been per facility policy.
28 Pa. Code 211.12(d)(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 clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for three of 3...
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Based on clinical records and staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for three of 36 residents reviewed (Residents 15, 33, 43).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 15, dated February 13, 2024, revealed that the resident was cognitively intact, was understood and understands, required assistance with care needs, had an unstageable deep tissue injury (pressure injury that affects the underlying soft tissues and may not be visible until advanced), and had diagnoses that included diabetes with diabetic neuropathy (nerve damage that affects people with diabetes).
Physician's orders for Resident 15, dated February 20, 2024, included and order for the resident to receive hydrocodone-acetaminophen 7.5-325 milligrams (mg) one tablet every six hours as needed for moderate to severe pain.
Review of the controlled drug record (a form that accounts for each tablet/pill/dose of a controlled drug) for Resident 15 for March 2024 revealed that staff signed out a dose of hydrocodone-acetaminophen for administration to the resident on March 24 at 8:00 p.m. However, there was no documented evidence in the resident's clinical record, including on the Medication Administration Record (MAR) and nursing notes, that the hydrocodone-acetaminophen was administered to the resident on the above listed date and time.
Interview with the Director of Nursing on April 25, 2024, at 3:20 p.m. confirmed that there was no documented evidence in Resident 15's clinical records to indicate that the signed-out dose of hydrocodone-acetaminophen was administered to the resident on the above-mentioned date and time.
A quarterly MDS assessment for Resident 33, dated March 21, 2024, revealed that the resident was cognitively intact and received an opioid (a controlled pain medication). Physician's orders, dated February 6, 2024, included orders for the resident to receive 1.5 tablets of 5 milligrams (mg) of Oxycodone (a narcotic pain medication) every six hours as needed for a pain rating of 7 to 10 (on a scale of 1 to 10, where 10 is the worst pain).
Resident 33's controlled substance records for March and April 2024 revealed that staff signed out doses of Oxycodone for administration to the resident on March 9 and 10 at 9:00 p.m., April 15 and 16 at 8:30 p.m., and April 20 and 21 at 9:00 p.m. However, there was no documented evidence in the resident's clinical record, including on the MAR and nursing notes, that the Oxycodone was actually administered to the resident at the above-listed dates and times.
Interview with the Director of Nursing on April 25, 2024, at 3:27 p.m. confirmed that there was no documented evidence that the staff administered the Oxycodone that was signed out on the controlled drug record on the above dates and times.
An quarterly MDS assessment for Resident 43, dated February 25, 2024, revealed that the resident was cognitively intact, was understood and understands, was independent with care needs, and received opiod medication. A care plan for Resident 43, dated March 23, 2022, revealed the resident had pain and to administer pain medication as ordered.
Physician's order for Resident 43, dated November 23, 2023, included an order for the resident to receive Oxycodone 5 mg one tablet every eight hours as needed for moderate pain.
Review of the controlled drug records for Resident 43 for January through April 2024 revealed that staff signed out a dose of Oxycodone for administration to the resident on January 18 at 7:58 p.m., January 20 at 8:00 p.m., January 22 at 10:30 p.m., January 23 at 8:40 p.m., January 28 at 9:00 p.m., February 10 at 8:40 p.m., March 6 at 8:00 p.m., March 13 at 8:00 p.m., March 19 at 8:00 p.m., March 31 at 8:30 p.m., April 1 at 8:40 p.m., April 2 at 8:00 p.m., April 4 at 7:30 p.m., April 6 at 8:10 p.m., and April 7 at 8:00 p.m. However, there was no documented evidence in the resident's clinical record, including on the MAR and nursing notes, that the Oxycodone was administered to the resident on the above-listed dates and times.
Interview with the Director of Nursing on April 24, 2024, at 11:19 a.m. confirmed that there was no documented evidence in Resident 43's clinical records to indicate that the signed-out doses of Oxycodone were administered to the resident on the above-mentioned dates and times.
28 Pa. Code 211.9(a)(1) Pharmacy Services.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected multiple residents
Based on resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable to residents.
Findings include:
During interviews with Re...
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Based on resident interviews, observations, and staff interviews, it was determined that the facility failed to serve food that was palatable to residents.
Findings include:
During interviews with Residents 3, 14, 33, and 36 on April 22, 2024, at 10:30 a.m., 11:51 a.m., and 2:22 p.m., the residents stated that the food served to them was disgusting and lousy. Interview with Resident 28 on April 22, 2024, at 11:58 a.m. revealed that the potatoes were not peeled when served.
Observations in the kitchen on April 23, 2024, at 11:24 a.m. revealed that the lunch meal consisted of chicken breast covered with gravy, oven-browned potatoes, corn, and sliced pears. These items were placed on a test tray, and the meal cart containing the test tray left the kitchen at 11:42 a.m. and arrived on the nursing unit at 11:43 a.m. The last resident was served and eating at 11:52 a.m At 12:00 p.m. the test tray was tasted, and the oven-browned potatoes were dry, bland and had the skin intact.
The recipe for oven-browned potatoes, undated, indicated that the potatoes were to be peeled and diced, and seasoned with garlic powder, paprika, and salt.
Interview with the Dietary Manager on April 23, 2024, at 12:34 p.m. confirmed that the potatoes were to be served with the skins removed and seasoned with garlic powder, paprika, and salt.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that food was served under sanitary condit...
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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 food was served under sanitary conditions.
Findings include:
The facility's policy regarding meal distribution, dated March 19, 2024, revealed that staff were to use proper food handling techniques to prevent contamination and that temperature maintenance controls will be used for point-of-service dining.
Observations in the main kitchen on April 22, 2024, at 8:42 a.m. and 11:06 a.m. revealed that four air vents on the right side of kitchen, on the upper wall, had a thick accumulation of dust and debris and six air vents on the left side of the kitchen, on the upper wall, had an accumulation of dust and debris.
A review of the maintenance kitchen vent cleaning log, undated, revealed that the kitchen vents were last cleaned on January 10, 2024.
Interview with the Dietary Manager on April 23, 2024, at 9:52 a.m. confirmed that there was an accumulation of dust and debris on the air vents and the maintenance department was to clean them.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 49, dated February 3, 2024, indicated that the resident was cognitively intact, was usually understood and could usually understand, and required supervision or touching assistance with eating. A care plan regarding activities of daily living for the resident, dated April 6, 2022, revealed that the resident required set-up help from staff to eat.
Observations of the lunch meal tray delivery to resident rooms on April 22, 2024, at 11:47 a.m. revealed that Nurse Aide 13 picked up the bun of a cheese burger and added mayo, then pressed the bun down with a bare hand. Interview with Nurse Aide 13 at 11:51 a.m. confirmed that staff are not to touch resident food with their bare hands, and that she did not know what she was thinking.
Interview with the Dietary Manager and the Nursing Home Administrator on April 23, 2024, at 9:53 a.m. confirmed that staff should not be touching food with their bare hands.
28 Pa. Code 211.6(f) Dietary Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ...
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Based on review of the facility's plans of correction 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 a State Survey and Certification (Department of Health) survey ending May 18 and November 17, 2023, and February 22, 2024, 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 April 25, 2024, identified repeated deficiencies related to a failure to complete accurate Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs), revising residents' care plans to include current care needs and interventions, to follow physician's orders, issues with oxygen therapy, medication accountability, and following proper infection control practices.
The facility's plan of correction for a deficiency regarding completing accurate MDS assessments, cited during the survey ending May 18, 2023, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan to ensure ongoing compliance with regulations regarding completing accurate MDS assessments.
The facility's plan of correction for a deficiency regarding revising residents' care plans to include current care needs, cited during the surveys ending May 18, 2023, and February 22, 2024, 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 was ineffective with maintaining compliance with the regulation regarding revising residents' care plans to include current care needs.
The facility's plan of correction for a deficiency regarding following physician's orders, cited during surveys ending May 18 and November 17, 2023, revealed that the facility developed a plan of correction that included completing audits and reporting the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the QAPI committee was ineffective in correcting deficient practices related to following physician's orders.
The facility's plan of correction for a deficiency regarding a failure to provide oxygen therapy as ordered by the physician, cited during the survey ending May 18, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F695, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding providing oxygen therapy as ordered by the physician.
The facility's plan of correction for a deficiency regarding the accountability of medications, cited during the survey ending May 18, 2023, revealed that the facility would complete audits and the results would be reviewed as part of quality assurance. The results of the current survey, cited under F755, revealed that the facility's QAPI committee was ineffective in maintaining compliance with the regulation regarding the accountability of medications.
The facility's plans of correction for deficiencies regarding following infection control practices, cited during the surveys ending May 18 and November 17, 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 F641, F657, F684, F695, F755, F880.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on review of established infection control guidelines, facility policies, documents, residents' clinical records, and employee files, as well as observations and staff interviews, it was determi...
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Based on review of established infection control guidelines, facility policies, documents, residents' clinical records, and employee files, 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 seven of 36 residents reviewed (Residents 14, 18, 28, 34, 41, 42, 68), and failed to ensure that proper infection control practices and techniques were followed after the hiring of two of five employees reviewed (Registered Nurse 2, Nurse Aide 5).
Findings include:
CDC guidance on isolation precautions for MRSA residents contained in Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicated that multidrug-resistant organism (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.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 14, dated March 28, 2024, revealed that the resident was cognitively intact, had a venous ulcer (wound caused by poor circulation in the legs), and received a treatment to the wound. A care plan for the resident, dated October 12, 2023, revealed that the resident had a venous ulcer wound to the right outer calf.
Physician's orders for Resident 14, dated March 26, 2024, included an order for the right lateral calf venous ulcer to be cleansed with wound cleanser, collagen applied to the wound bed, covered with a dressing, wrapped with gauze and Tubigrip (supportive wraps to reduce swelling), and applied three times a week.
Observations of Resident 14 on April 22, 2024, at 10:30 a.m. and 12:00 p.m. revealed that the resident was in her room, and there was no infection control sign posted at the entrance to the resident's room.
An annual MDS assessment for Resident 18, dated February 1, 2024, revealed that the resident was cognitively intact, was clearly understood and could clearly understand others, required assistance with care needs, had two chronic venous ulcers (ulcers caused by problems with blood flow in the leg veins) to the right and left lower legs, and had diagnoses that included venous insufficiency (a disease causing poor blood circulation to lower limbs) and protein-calorie malnutrition (lack of dietary protein). A care plan, dated May 30, 2023, revealed that the resident had venous ulcers to his left circumferential lower leg and right lower extremity.
Physician's orders for Resident 18, dated April 15, 2024, included an order for staff to cleanse the resident's left and right circumferential lower legs with soap and water, rinse with normal saline (a sterile solution used for the moistening of wound dressings and wound debridement), pat dry, moisturize dry skin with ammonium lactate 2 percent lotion, paint all wounds with betadine (an solution used to treat and prevent infection), and allow to dry. Apply adaptic dressing (dressing used to absorb and retain drainage) over wounds after the betadine dries and cover with an abdominal dressing (ABD) then with 4 centimeter (cm) by 4 cm dry gauze and secure with Kerlix (bandage wrap) and tape every day shift and as needed for soilage and dislodgement. Use a single layer Tubigrip (a support bandage) size D as tolerated every day and as needed for soilage and dislodgement.
Observations of Resident 18 on April 22, 2024, at 10:53 a.m. and April 24, 2024, at 12:10 p.m. revealed that the resident had no signage at the entrance to his room to indicate infection control measures for EBP related to his chronic wounds.
A quarterly MDS assessment for Resident 28, dated April 19, 2024, revealed that the resident was understood, could understand others, had a indwelling catheter (a tube inserted into the bladder to drain urine), and had a diagnosis which included a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle) of the sacral region (the portion of your spine between the lower back and tailbone). A care plan for the resident, dated April 14, 2024, revealed that the resident has an indwelling catheter. A care plan, dated October 20, 2023, revealed that the resident has a surgical wound to his perianal area (area around the anus) related to a fissure (a tear in the inside lining of the anus). A care plan, dated February 16, 2024, revealed that the resident has a pressure ulcer to his coccyx (tailbone area).
Physician's orders for Resident 28, dated May 9, 2022, included an order for staff to perform catheter care every shift and as needed.
Physician's orders for Resident 28, dated May 9, 2022, included an order for staff to change the catheter bag as needed.
Physician's orders for Resident 28, dated May 10, 2022, included an order for staff to change the catheter as needed when clogged and/or leaking.
Physician's orders for Resident 28, dated October 19, 202, included an order to for staff to cleanse the perianal fissure wound with normal sterile saline (NSS - a sterile solution used for the moistening of wound dressings and wound debridement), pat dry, dust with stoma powder (used to absorb moisture from broken skin around the stoma), and then lightly pack with calcium alginate (a type of wound dressing) twice a day and as needed.
Physician's orders for Resident 28, dated March 30, 2024, included an order for staff to change the wound vac dressings every Tuesday, Thursday, and Saturdays and as needed every day shift.
Observations of Resident 28 on April 22, 2024, at 11:50 a.m.; April 23, 2024, at 1:15 p.m.; and April 24, 2024, at 8:20 a.m. revealed that the resident was in his room, and there was no infection control sign posted at the entrance to the resident's room.
An annual MDS assessment for Resident 34, dated February 29, 2024, revealed that the resident had cognitive deficits, was usually understood and usually understands, had an indwelling catheter, and had a diagnosis that included neurogenic bladder (bladder lacks control due to nerve or muscle problems). A care plan, dated April 11, 2022, revealed that the resident had a suprapubic indwelling catheter (a flexible tube that drains urine from the bladder through the abdomen).
Physician's orders for Resident 34, dated April 8, 2022, included orders for the catheter bag to be changed as needed, catheter care every shift and as needed, and irrigate the catheter for blockage and/or leakage with 5 to 10 cubic centimeters (cc) of normal saline as needed.
Physician's orders for Resident 34, dated July 23, 2022, included an order to change the catheter as needed for blockage.
Physician's orders for Resident 34, dated August 23, 2022, included an order to cleanse the suprapubic catheter site with normal saline, apply bacitracin, and apply a T-drain sponge (a pre-cut bandage used to fit snug around catheters) every shift.
Special instructions in Resident 34's electronic health record indicated that he was on contact isolation for proteus species in the urine. There was no documented evidence that contact precautions or EBP were in place for this resident.
Observations of Resident 34 on April 22, 2024, at 11:15 a.m. and on April 23, 2024, at 10:46 a.m. revealed that the resident had no signage at the entrance to his room to indicate infection control measures for contact precautions or EBP were in place related to his indwelling catheter and documented proteus species in his urine.
An admission MDS for Resident 41, dated March 21, 2024, revealed that the resident had cognitive deficits, was usually understood and usually understands, required assistance with care needs, and had a Stage 2 pressure ulcer (pressure wound with superficial skin loss) to the bilateral buttocks (resolved March 26, 2024) and an unstageable pressure ulcer (full-thickness pressure injuries in which the base is obscured by slough and/or eschar) to the right heel. A care plan, dated April 17, 2024, revealed that the resident had an open wound to his right heel.
Physician's orders for Resident 41, dated April 16, 2024, included an order to cleanse the right heel with wound cleanser, pat dry, paint with Betadine, cover with collagen alginate, then ABD pad, and wrap with Kerlix three times per week every day shift every Tuesday, Thursday, Saturday and as needed for soiling or dislodging.
Observations of Resident 41 on April 22, 2024, at 11:32 a.m. revealed that the resident had no signage at the entrance to his room to indicate infection control measures for EBP related to his right heel wound.
An annual MDS for Resident 42, dated February 1, 2024, indicated that the resident was cognitively intact, requires assistance from staff for his care needs, had an indwelling catheter, and had a diagnosis of a neurogenic bladder.
Physician's orders for Resident 42, dated September 9, 2022, included an order for staff to perform catheter care every shift and as needed, and included an order for a catheter bag change as needed and for facility staff to monitor the catheter for patency and drainage.
Physician's orders for Resident 42, dated February 20, 2023, included an order for facility staff to irrigate the catheter for blockage and leakage with 60 milliliters (ml) of sterile water for lack in drainage, and if greater than two weeks change the Foley catheter prior to irrigation and reevaluate as needed.
Physician's orders for Resident 42, dated October 11, 2023, included an order for the resident to have a Foley catheter sized 18 French and 30 cc balloon size for a diagnosis of neurogenic bladder.
Observations of Resident 42 on April 22, 2024, at 12:13 p.m.; April 24, 2024, at 1:46 p.m.; and April 25, 2024, at 8:53 a.m. revealed that the resident had no signage at the entrance to his room to indicate infection control measures for contact precautions or EBP were in place related to his indwelling catheter. On April 25, 2024, at 8:53 a.m. Resident 42 was lying in bed with his catheter bag attached to the left side of his bed.
An admission MDS assessment for Resident 68, dated March 5, 2024, revealed that the resident was understood, could understand others, had an indwelling catheter, had a diagnosis which included multidrug resistant organism (MDRO - a germ that is resistant to many antibiotics), had one Stage 2 pressure injury (a break in the top two layers of skin) that was present upon admission, and had one unstageable pressure injury (a term that refers to an ulcer that has full thickness tissue loss) that was present upon admission. A care plan for the resident, dated February 29, 2024, revealed that the resident has a indwelling catheter. A care plan, dated March 5, 2024, revealed that the resident has a wound to his right gluteal crease. A care plan, dated March 10, 2024, revealed that the resident has an open area to his coccyx.
Physician's orders for Resident 68, dated February 29, 2024, included an order for staff to perform catheter care every shift and as needed.
Physician's orders for Resident 68, dated March 10, 2024, included an order for staff to cleanse his coccyx wound with NSS, pat dry, apply Medihoney (a medical-grade honey intended for wound care), and cover with a dry dressing daily and as needed.
Physician's orders for Resident 68, dated March 10, 2024, included an order for staff to cleanse his right ischium wound with NSS, pat dry, apply Medihoney (a medical-grade honey intended for wound care), and cover with a dry dressing daily and as needed.
Observations of Resident 68 on April 22, 2024, at 12:09 p.m.; April 23, 2024, at 1:15 p.m.; and April 24, 2024, at 8:20 a.m. revealed that the resident was in his room, and there was no infection control sign posted at the entrance to the resident's room.
Interview with the Assistant Director of Nursing and Infection Preventionist on April 23, 2024, at 10:46 a.m. confirmed that she was unaware of the new guidance for EBP effective April 1, 2024, per CMS and CDC guidelines, and confirmed that she was not following the new regulatory recommendations for the above-mentioned residents and she should have.
The facility's policy regarding employee screening for Tuberculosis (TB), dated March 19, 2024, revealed that all employees must be tested for TB prior to beginning employment and annually thereafter. Each newly hired employee will be screened for TB after an employment offer has been made but prior to the employee's duty assignment. A new employee undergoing the purified protein derivative (PPD) two-step testing (used to detect individuals with past TB infection) may participate in non-resident care activities (no direct resident contact) following an initial negative first step PPD while waiting completion of the testing if they have no symptoms of active TB.
The personnel file for Registered Nurse 2 revealed a hire date of March 4, 2024. Time punches and staff assignment/deployment sheets revealed that she worked on a resident care unit on March 22, 2024. However, documentation revealed that she did not receive her first step PPD test until March 25, 2024, and then received her second step PPD test on April 3, 2024.
Interview with Registered Nurse 2 on April 24, 2024, at 4:30 p.m. confirmed that she worked on March 22, 2024. She indicated that there was a call off and that she had to work the medication cart to pass the residents their medications.
The personnel file for Nurse Aide 5 revealed a hire date of January 20, 2024. Time punches and staff assignment/deployment sheets revealed that she worked on a resident care unit on February 7, 2024. However, there was no documented evidence that she had received her first step PPD test or her second step PPD test prior to working in a resident care unit.
Interview with the Assistant Director of Nursing/Infection Control Preventionist on April 25, 2024, at 9:05 a.m. confirmed that Registered Nurse 2 and Nurse Aide 5 should not have worked on resident care units prior to being tested for TB.
28 Pa. Code 201.14(a) Responsibility of Licensee.
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 211.12(d)(1)(5) Nursing Services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0947
(Tag F0947)
Could have caused harm · This affected multiple residents
Based on a review of a list of nurse aides currently employed by the facility, including their hire dates and training hours, as well as staff interviews, it was determined that the facility failed to...
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Based on a review of a list of nurse aides currently employed by the facility, including their hire dates and training hours, as well as staff interviews, it was determined that the facility failed to ensure that nurse aides had 12 hours of in-service training annually for three of three nurse aides reviewed (Nurse Aide 10, Nurse Aide 11, Nurse Aide 12), failed to ensure that nurse aides received annual in-service training regarding abuse for three of three nurse aides reviewed (Nurse Aide 10, Nurse Aide 11, Nurse Aide 12), and failed to ensure that nurse aides received annual in-service training regarding dementia for one of three nurse aides reviewed (Nurse Aide 12).
Findings include:
A list of nurse aides provided by the facility revealed that based on their months and days of hire:
Nurse Aide 10 should have received at least 12 hours of in-service training between March 25, 2023, and March 25, 2024. However, there was no documented evidence that she received at least 12 hours of in-service training as required.
Nurse Aide 11 should have received at least 12 hours of in-service training between March 7, 2023, and March 7, 2024. However, there was no documented evidence that she received at least 12 hours of in-service training as required.
Nurse Aide 12 should have received at least 12 hours of in-service training between March 11, 2023, and March 11, 2024. However, there was no documented evidence that she received at least 12 hours of in-service training as required.
The facility's policy regarding abuse, neglect, exploitation, and misappropriation, dated March 19, 2024, indicated that employees of the center will receive education and training on resident rights, resident abuse, and abuse reporting during orientation and annually thereafter. Additional education and training will be provided as deemed necessary.
Review of personnel records for Nurse Aide 10 revealed a hire date of March 25, 2010. However, there was no documented evidence that she received the facility's annual resident abuse training and abuse reporting training during the time period of March 25, 2023, through March 25, 2024.
Review of personnel records for Nurse Aide 11 revealed a hire date of March 7, 2018. However, there was no documented evidence that she received the facility's annual resident abuse training and abuse reporting training during the time period of March 7, 2023, through March 11, 2024.
Review of personnel records for Nurse Aide 12 revealed a hire date of March 11, 2009. However, there was no documented evidence that she received the facility's annual resident abuse, abuse reporting, and dementia training during the time period of March 11, 2023, through March 11, 2024.
Interview with the Assistant Director of Nursing/Infection Control Preventionist on April 25, 2024, at 3:02 p.m. confirmed that there was no documented evidence that the above nurse aides received at least 12 hours of in-service training as required or received the facility's annual resident abuse, abuse reporting, and dementia training.
28 Pa. Code 201.20(a) Staff Development.
Feb 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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of policies, clinical records, and information submitted by the facility, as well as staff interviews, it was determined that the facility failed to review and revise care plans for on...
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Based on review of policies, clinical records, and information submitted by the facility, as well as staff interviews, it was determined that the facility failed to review and revise care plans for one of three residents reviewed
(Resident 2).
Findings include:
The facility's policy regarding care plans, dated February 1, 2024, revealed 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. The care plan interventions are derived from a thorough analysis of information gathered as part of the comprehensive assessment. The comprehensive, person-centered care plan describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of the residents are ongoing and care plans are revised as information about the residents and the resident's condition change. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's condition; when the desired outcome has not been met; when the resident has been readmitted to the facility from a hospital stay, and at least quarterly. Revisions of the care plan will occur with changes in physician orders, recommendations, consults, and/or anything that affects patient center care.
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated February 1, 2024, revealed that the resident was understood, could understand others, and had a diagnosis of Parkinson's disease.
Observations of Resident 2 on February 22, 2024, at 11:58 a.m. revealed that the resident was in bed feeding himself his lunch meal. The resident's utensils had round, blue foam build-ups (assistive devices that are added to give greater control to people who lack coordination, strength or gripping ability) and he also had two two-handled sippy cups (easier to grip and control for individuals with a weak grip or tremors) with lids and straws.
A task note for Resident 2, dated April 17, 2023, revealed that staff were to provide set-up assistance with his meals and give the resident two-handled sippy cups with his meals.
Resident 2's current care plan, as of February 22, 2024, did not reflect that the resident was to have the round, blue foam build-ups on his utensils and the two-handled sippy cups with his meals.
Interview with the Rehab Director on February 22, 2024, at 3:35 p.m. revealed that Resident 2 has used the round, blue foam build-ups on his utensils for a long time. She revealed that she could not find the exact date because of the change in ownership.
Interview with the Director of Nursing on February 22, 2024, at 3:30 p.m. revealed that registered nurse must have caught it and changed it today.
28 Pa. Code 211.12(d)(5) Nursing Services.
Nov 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected 1 resident
Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the Certified Registered Nurse Practioner (CRNP - an adv...
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Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the Certified Registered Nurse Practioner (CRNP - an advanced practice registered nurse who can work independently from a physician) wrote, signed, and dated progress notes with each visit for one of 18 residents reviewed (Resident 11).
Findings include:
The facility's policy regarding coordination of medical care, dated October 6, 2023, indicated that the physician would be responsible for creating and managing systems to ensure that practitioners who may perform physician-delegated tasks act within the regulatory requirements and the scope of practices as defined by state law.
A CRNP note for Resident 11, dated October 30, 2023, revealed that the CRNP ordered for the resident to get a chest x-ray and to test for COVID.
There was no documented evidence that the resident was tested for COVID per the CRNP's orders.
A CRNP note for Resident 11, dated November 6, 2023, revealed that the CRNP ordered for the resident to get intravenous (IV) fluids now, insert a midline (a long, thin, flexible tube that is inserted into a large vein in the upper arm), and have speech therapy see the resident for a swallow evaluation.
There was no documented evidence that the resident received the IV fluids ordered by the CRNP, or that a midline was inserted timely, or that the resident received a speech therapy swallow evaluation.
An interview with the Assistant Director of Nursing on November 17, 2023, at 3:15 p.m. revealed that the CRNP visits the residents one day, but the facility does not receive the CRNP's notes until days later and the CRNP does not give verbal or written orders to the nursing staff. Therefore, Resident 11 did not receive the orders that the CRNP had ordered for her.
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 guidance from the Pennsylvania Department of Health (DOH) and review of the facility's policies, as well as observations and staff interviews, it was determined that the facility fa...
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Based on review of guidance from the Pennsylvania Department of Health (DOH) and review of the facility's policies, as well as observations and staff interviews, it was determined that the facility failed to follow infection control standards and DOH guidelines to reduce the spread of infections and prevent cross-contamination for one of 18 residents reviewed (Resident 1).
Findings include:
The COVID-19 Infection Control and Outbreak Response Toolkit for Long-Term Care, dated July 2023, revealed that symptomatic residents should be tested with even mild symptoms of COVID-19 as soon as possible.
The facility's policy regarding transmission-based precautions for COVID-19, dated October 6, 2023, indicated that the facility would follow federal and state guidelines regarding testing residents for COVID-19.
A nursing note for Resident 11, dated October 27, 2023, revealed that the resident had a change in condition, her cheeks were reddened and warm to touch, and her oxygen level was lower. There was no documented evidence that the resident was tested for COVID after developing those symptoms.
A nursing note for Resident 11, dated October 28, 2023, revealed that the resident had a fever of 101.2 degrees Fahrenheit, was flushed, and was using abdominal muscles for breathing. There was no documented evidence that the resident was tested for COVID after developing those symptoms.
A Certified Registered Nurse Practioner (CRNP - advanced practice nurse) ordered for Resident 11 to be tested for COVID-19 on October 30, 2023; however, there was no documented evidence that the resident was tested for COVID on that date.
A nursing note, dated November 2, 2023, revealed that Resident 11 was tested for COVID-19 and was positive on that date.
Interview with the Assistant Director of Nursing on November 17, 2023, at 3:15 p.m. confirmed that Resident 11 was not tested for COVID on October 27 or October 28 when she was showing symptoms, or on October 30 when the CRNP ordered her a COVID test, and that she should have been.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on clinical records reviews and staff interviews, it was determined that the facility failed to ensure that intravenous fluids were administered according to physician's orders for one of 18 res...
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Based on clinical records reviews and staff interviews, it was determined that the facility failed to ensure that intravenous fluids were administered according to physician's orders for one of 18 residents reviewed (Resident 10) and failed to ensure that Certified Registered Nurse Practioner's (CRNP - an advanced practice registered nurse who can work independently from a physician) orders were followed for one of 18 residents reviewed (Resident 11).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 10, dated September 15, 2023, indicated that the resident was cognitively intact and required extensive assistance for daily care needs.
A nursing note, dated November 3, 2023, at 9:19 p.m. revealed that Resident 10 was seen and examined by the physician during the evening after being seen earlier in the day at the emergency room. Physician's orders were received for 1/2 normal saline (half strength salt water) IV at 100 milliliters per hour (ml/hr) for three days for dehydration and to increase the resident's oral potassium to 40 milliequivalents (meq) three times a day for three days.
A physician's progress note, dated November 3, 2023, revealed that Resident 10 was sent out to the emergency room secondary to significant problems with a decline in his condition and had nausea and vomiting. He indicated that the resident should have remained in the hospital but they sent him back, so they would institute IV fluids at that time and monitor him closely.
A nursing note, dated November 3, 2023, at 10:22 p.m. revealed that the physician was notified that 1/2 normal saline was not available at the facility and agreed to start the intravenous (IV - administered directly into a vein) fluids when it arrived from pharmacy. He also indicated that if it was too difficult to obtain IV access, they could initiate a midline or PICC line (soft tube inserted into a peripheral vein for long term venous access).
A nursing note, dated November 4, 2023, at 4:36 p.m. revealed that a midline was placed at approximately 4:30 p.m. However, there was no documented evidence that staff attempted to obtain IV access prior to a midline being placed at 4:30 p.m. on November 4, 2023, and there was no documented evidence that the resident received 1/2 normal saline as ordered.
A nursing note, dated November 4, 2023, at 6:44 p.m. revealed that a new order was received from the physician to send Resident 10 to the emergency room for evaluation and treatment.
Interviews with the Assistant Director of Nursing on November 17, 2023, at 4:21 p.m. confirmed that there was no documented evidence that staff attempted to obtain IV access for Resident 10 prior to starting a midline and no documented evidence that the resident received IV fluids as ordered.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 11, dated November 2, 2023, revealed that the resident was cognitively impaired and required extensive assistance from staff for her daily care needs.
A CRNP note for Resident 11, dated October 30, 2023, revealed that the CRNP ordered for the resident to get a chest x-ray and to test for COVID.
There was no documented evidence that the resident was tested for COVID per the CRNP's orders.
A CRNP note for Resident 11, dated November 6, 2023, revealed that the CRNP ordered for the resident to get intravenous (IV) fluids now, insert a midline (a long, thin, flexible tube that is inserted into a large vein in the upper arm), and have speech therapy see the resident for a swallow evaluation.
There was no documented evidence that the resident received the IV fluids ordered by the CRNP, or that a midline was inserted timely, or that the resident received a speech therapy swallow evaluation.
An interview with the Assistant Director of Nursing on November 17, 2023 at 3:15 p.m. revealed that the CRNP visits the residents one day, but the facility does not receive the CRNP's notes until days later and the CRNP does not give verbal or written orders to the nursing staff. Therefore, Resident 11 did not receive the orders that the CRNP had ordered for her.
28 Pa. Code 211.12(d)(3)(5) Nursing services.
Jun 2023
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on review of facility policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to report an allegation of abuse for one of six resident...
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Based on review of facility policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to report an allegation of abuse for one of six residents reviewed (Resident 2).
Findings include:
The facility's policy regarding abuse, dated January 13, 2023, revealed that the facility will initiate investigation immediately for any allegations of abuse.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 19, 2023, revealed that the resident was cognitively intact and had diagnoses that included intellectual disabilities.
An interview with Resident 2 on June 28, 2023, at 11:11 a.m. revealed that she remembered pulling the fire alarm several months ago (unsure of when exactly) and that a big man yelled at her for pulling it and told her not to do it again.
An interview with the Maintenance Director on June 28, 2023, at 10:45 a.m. revealed that several months ago (unsure of the date) Resident 2 had pulled the fire alarm on her hall and staff ran to the hall to respond. The Director of Nursing at that time went to Resident 2 and screamed at her asking her why she did it and telling her not to do it again. He stated that Resident 2 was staring at the Director of Nursing while he was yelling at her and that the Nursing Home Administrator (a previous administrator, not the current one) had witnessed the event as he was standing right next to them when this occurred. However, there was no documented evidence that the facility initiated an investigation into the alleged verbal abuse of Resident 2.
Interview with the Nursing Home Administrator on June 28, 2023, at 12:20 p.m. confirmed that there was no evidence that the facility investigated the alleged incident of possible verbal abuse or reported the incident involving possible verbal abuse of Resident 2 to the Department of Health and the Area Agency on Aging.
42 CFR §483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.
Chapter 51.3(f) Notification.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to complete and submit a thorough investigation into an incident ...
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Based on review of policies and clinical records, as well as resident and staff interviews, it was determined that the facility failed to complete and submit a thorough investigation into an incident involving potential verbal abuse for one of six residents reviewed (Resident 2).
Findings include:
The facility's policy regarding abuse, dated January 13, 2023, indicated that the residents had the right to be free from abuse. The policy included that all allegations of abuse would be reported to the Department of Health and Area Agency on Aging.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated May 19, 2023, revealed that the resident was cognitively intact and had diagnoses that included intellectual disabilities (mentally retarded).
An interview with Resident 2 on June 28, 2023, at 11:11 a.m. revealed that she remembered pulling the fire alarm several months ago (unsure of when exactly) and that a big man yelled at her for pulling it and told her not to do it again.
An interview with the Maintenance Director on June 28, 2023, at 10:45 a.m. revealed that several months ago (unsure of the date) Resident 2 had pulled the fire alarm on her hall and staff ran to the hall to respond. The Director of Nursing at that time went to Resident 2 and screamed at her asking her why she did it and telling her not to do it again. He stated that Resident 2 was staring at the Director of Nursing while he was yelling at her and that the Nursing Home Administrator (a previous administrator, not the current one) had witnessed the event as he was standing right next to them when this occurred. However, there was no documented evidence that the facility initiated an investigation into the alleged verbal abuse of Resident 2.
Interview with the Nursing Home Administrator on June 28, 2023, at 12:20 p.m. confirmed that there was no documented evidence that a thorough investigation of the incident involving Resident 2 pulling the fire alarm and the Director of Nursing screaming at her and that there should have been. He stated that he was not employed at the facility at that time the incident occurred and that the Director of Nursing involved in the allegation no longer worked at the facility.
42 CFR §483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition.
28 Pa. Code 201.18(e)(1) Management.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
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' clinical records were complete and accurate...
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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' clinical records were complete and accurately documented for one of five residents reviewed (Resident 5).
Findings include:
The facility's policy for Charting and Documentation, dated January 13, 2023, indicated that all services provided to the resident would be documented in the resident's medical record.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 5, dated May 4, 2023, revealed that the resident was confused and required assistance from staff for his daily care needs.
Physician's orders for Resident 5, dated January 30, 2023, included an order for the resident to have his right tibia (lower leg) cleansed with wound cleanser, then apply 40 percent zinc oxide to the intact skin, apply full strength betadine, and cover with gauze twice per day.
Resident 5's Treatment Administration Record (TAR) for May and June 2023 revealed that the resident's tibia wound treatment was discontinued on May 22, 2023, and that a new order for wound care to the resident's tibia was ordered on June 22, 2023.
A nursing note for Resident 5, dated June 22, 2023, indicated that the treatment for the resident's tibia wound was accidentally discontinued on May 26, 2023, and that it should not have been.
Interview with Registered Nurse 1 on June 28, 2023, at 14:32 p.m. revealed that Resident 5 was receiving wound care to his tibia wound when staff were doing the wound care to his other leg wounds; however, they were not documenting in the resident's medical record and they should have been.
Interview with the Nursing Home Administrator on June 28, 2023, at 4:24 p.m. revealed that the staff were to document in the resident's medical record when they performed the wound care and they did not.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(d)(5) Nursing services.
May 2023
14 deficiencies
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, as well as 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-...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or responsible party was notified about the facility's bed-hold policy upon transfer to the hospital for one of 38 residents reviewed (Resident 59).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 59, dated May 3, 2023, revealed that the resident was cognitively impaired, required extensive assistance with daily care needs, and had diagnoses that included diabetes mellitus and chronic kidney disease.
Nurse's notes for Resident 59 dated March 22, 2023, at 7:25 p.m. revealed that the resident was admitted to the hospital for a change in condition.
There was no documented evidence that the resident and/or the responsible party was notified about the facility's bed-hold policy at the time of the above transfer to the hospital for Resident 59.
Interview with the Nursing Home Administrator on May 17, 2023 at 9:26 a.m. confirmed that there was no documented evidence that a bed hold notice was issued to Resident 59 or his responsible party and that it should have been.
28 Pa. Code 201.29(d) Resident rights.
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 a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Se...
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Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for four of 38 residents reviewed (Residents 8, 18, 25, 80).
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October, 2019, indicated that the intent of Section O was to record special treatments and programs that were provided to the resident during the seven-day lookback period. Section O0250C was to be coded with the reason the influenza vaccine was not received.
A quarterly MDS assessment for Resident 8, dated February 28, 2023, indicated that the resident was usually understood and could usually understand others, required extensive assistance from staff for his daily care tasks, and had a diagnosis that included dysarthria (speech disorder caused by muscle weakness). Section O0250C revealed that the resident was offered but declined the influenza vaccine.
An Informed Consent for Influenza Vaccine form for Resident 8, dated December 27, 2022, revealed that the resident gave consent to receive the influenza vaccine. There was no documented evidence that the resident declined or refused the influenza vaccine.
The RAI User's Manual, dated October 2019, revealed that Section O0100 was to be completed for the resident's special treatments, procedures, and programs. Section O0100C was to be coded for the use of oxygen. Column (1) was to be checked if oxygen was used while not a resident of the facility within the last 14 days, and column (2) was to be checked if oxygen was used while a resident of the facility within the last 14 days.
Physician's orders for Resident 18, dated January 6, 2023, included an order for the resident to receive continuous oxygen at 2 liters per minute (flow rate) via nasal cannula (tubes that deliver oxygen into the nostrils) and to titrate (adjust the flow rate) as needed to ensure that the oxygen concentration/pulse oximetry (percentage of oxygen in blood) was equal to or greater than 90 percent every shift. The resident's Medication Administration Records (MAR's) for April and May 2023 indicated that the resident used oxygen daily at 2 liters per minute. However, a quarterly MDS assessment for Resident 18, dated May 4, 2023, revealed that Section O0100C, Column 2 was not checked to indicate that the resident used oxygen during the 14-day assessment period.
Interview with the Interim Nursing Home Administrator on May 18, 2023, at 10:05 a.m. confirmed that Section O0100C, Column 2 was not coded correctly on Resident 18's MDS assessment of May 4, 2023.
The RAI User's Manual, dated October 2019, indicated that the intent of Section N0350A was to record the number of days the resident received insulin during the seven-day look-back period. The intent of Section N0410E was to record the number of days the resident received an anticoagulant (blood thinner) during the seven-day look-back period. The intent of Section N0410G was to record the number of days the resident received a diuretic (increases the amount of urine made by the body) during the seven-day look-back period.
Physician's orders for Resident 25, dated November 25, 2022, included an order for the resident to receive 5 milligrams (mg) of Eliquis (an anticoagulant) two times a day. Review of the May 2023 MAR for Resident 25 revealed that the resident was given Eliquis seven days during the look-back period. There was no documented evidence that a diuretic was administered.
A quarterly MDS for Resident 25, dated May 14, 2023, revealed that the resident was understood and able to understand others, required supervision with daily care needs, and had diagnoses that included Down Syndrome. Section N0410E was coded as (0), indicating the resident did not receive an anticoagulant during the look-back period. Section N0410G was coded as (7), indicating the resident received a diuretic seven days during the look-back period.
A quarterly MDS for Resident 80, dated February 22, 2023, revealed that the resident was cognitively intact, required supervision with daily care needs, and had diagnoses that included diabetes. Section N0350A was coded as (7), indicating the resident received insulin seven days during the look-back period. Section N0410G was coded as (7), indicating the resident received a diuretic seven days during the look-back period.
There was no documented evidence that Resident 80 had a physician's order for insulin or a diuretic, and a review of the MAR for Resident 80 for February 2023 revealed no documentation that the resident received insulin or a diuretic during the seven-day look-back period.
An interview with the Nursing Home Administrator on May 18, 2023, at 10:55 a.m. confirmed that the above-mentioned MDS assessments for Residents 8, 25, and 80 were coded incorrectly.
28 Pa. Code 211.5(f) Clinical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
Based on review of facility policy 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 th...
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Based on review of facility policy and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 38 residents reviewed (Residents 25, 35).
Findings include:
The facility's policy for plans of care, dated January 13, 2023, indicated that the facility will review, update and/or revise the comprehensive plan of care based on changing goals, preferences, and needs of the resident, in response to current interventions after the completion of each Minimum Data Set assessment and as needed.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated May 14, 2023, revealed that the resident was understood and able to understand others, required supervision with daily care needs, and had diagnoses that included Down's Syndrome.
A review of care plans for Resident 25, dated November 18, 2022, revealed that the resident had a deep vein thrombosis (blood clot) to the right lower leg. The care plan included interventions to check for the presence of pedal pulses every eight hours and monitoring the right leg circumference every day. There was no documented evidence that these interventions were being completed.
An interview with the Director of Nursing on May 17, 2023, at 11:18 a.m. revealed that the resident no longer had a deep vein thrombosis and that the care plan should have been revised to indicate that the resident was at risk for a deep vein thrombosis; however, the care plan was not revised.
A quarterly MDS assessment for Resident 35, dated April 19, 2023, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had diagnoses that included diabetes and high blood pressure.
A tube feeding care plan for Resident 35, dated May 24, 2022, revealed that the resident required a tube feeding. A physician's order for the resident, dated December 2, 2022, included an order to discontinue the tube feeding.
An interview with the Nursing Home Administrator on May 18, 2023, at 8:45 a.m. confirmed that Resident 35 no longer received tube feedings and that his care plan was not revised and should have been.
28 Pa. Code 211.11(d) Resident care plan.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of 38 residents rev...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for medications were followed for two of 38 residents reviewed (Residents 25, 77).
Findings include:
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 25, dated May 14, 2023, revealed that the resident was understood and able to understand others, required supervision with daily care needs, and had diagnosis that included Down's Syndrome.
Physician's orders for Resident 25, dated August 30, 2022, included and order for the resident to wear tubigrip (elastic bandage that provides compression to reduce swelling) to bilateral lower extremities from toe to knee, on every morning and off every evening for edema (swelling).
Resident 25's potential for impaired skin integrity care plan, dated April 14, 2023, included an intervention to use tubigrip to bilateral lower extremities from toe to knee, on every morning and off every evening for edema.
Review of the Medication Administration Records (MAR) for Resident 25 for April and May 2023 revealed no documented evidence that tubigrip was worn on the resident as ordered.
Observations on May 16, 2023, at 1:52 p.m. revealed that Resident 25 sitting in his wheelchair in his room wearing socks and sneakers. There were no tubigrip or compression stockings of any kind on his legs. An interview with the Director of Nursing at that time confirmed that the resident was not wearing tubigrip.
Interview with the Director of Nursing on May 17, 2023, at 11:18 p.m. confirmed that Resident 25 had a physician's order to wear tubigrip on his bilateral lower legs; however, there was no documented evidence in the previous two months that the resident had worn the tubigrip as ordered.
A quarterly MDS assessment for Resident 77, dated February 22, 2023, revealed that the resident was sometimes understood, could sometimes understand, and had a diagnosis of hypothyroidism (when the thyroid gland does not make enough thyroid hormones to meet your body's needs). A care plan for the resident, dated February 21, 2023, revealed that the resident had hypothyroidism and staff was to give the resident's thyroid replacement therapy as ordered.
Physician's orders for Resident 77, dated April 4, 2023, included an order for the resident to receive one 175 microgram (mcg) tablet of Levothyroxine (a medicine used to treat an underactive thyroid gland (hypothyroidism) every morning.
A review of the April 2023 MAR's for Resident 77 revealed that there was no documented evidence that the resident was administered the 175 mcg tablet of Levothyroxine on April 7, 14, and 18, 2023.
Interview with the Assistant Director of Nursing on May 18, 2023, at 10:45 a.m. confirmed that there was no documented evidence that Resident 77 was administered the 175 mcg tablet of Levothyroxine on April 7, 14, and 18, 2023.
28 Pa. Code 211.12(d)(1)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were monitored for one of 38 residents reviewed (Resident 35...
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Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that pressure ulcers were monitored for one of 38 residents reviewed (Resident 35).
Findings include:
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 35, dated April 19, 2023, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had diagnoses that included diabetes and the presence of open wounds.
A care plan for the potential for impaired skin integrity for Resident 35, dated May 10, 2022, indicated that the care and treatment included weekly wound assessments with documentation to include the width, length, depth, type of tissue, exudate, and any other notable changes or observations for each area of skin breakdown.
A review of Resident 35's clinical record, including nursing notes, physician's notes, and wound clinic consultations, revealed no documented evidence that weekly wound assessments were completed as care planned.
A wound clinic consultation for Resident 35 revealed that the resident had a follow up appointment scheduled for May 23, 2023.
An interview with the Director of Nursing and Registered Nurse 1 on May 17, 2023, at 3:15 p.m. confirmed that weekly wound assessments were not done in the facility. The resident is followed by an outside wound clinic and they determine the resident's wound treatments.
An interview with the Director of Nursing on May 18, 2023, at 2:51 p.m. confirmed that Resident 35's care plan indicated to complete weekly wound assessments, so they should have been completed.
An interview with the Nursing Home Administrator on May 18, 2023, at 8:45 a.m. confirmed that there was no documentation of weekly wound assessments for Resident 35.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
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 certified registered nurse practitioner wrote progress notes with each visit for on...
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Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that the certified registered nurse practitioner wrote progress notes with each visit for one of 38 residents reviewed (Resident 78).
Findings include:
A nursing note for Resident 78, dated February 6, 2023, revealed that Certified Registered Nurse Practitioner 4 (CRNP - a registered nurse with advanced training and the authority to write orders for treatment) saw the resident during wound rounds. New orders were received to cleanse the resident's coccyx (also know as the tailbone) with wound cleanser, apply triple antibiotic ointment, cover with border foam, and change the dressing every two days and as needed. However, CRNP 4's progress note for Resident 78, dated February 6, 2023, did not include his assessment of the resident's wound to her coccyx area.
A nursing note for Resident 78, dated February 13, 2023, revealed that CRNP 4 saw the resident during wound rounds. New orders were received to cleanse the resident's right ischium (forms the lower and back part of the hip bone) with normal sterile saline (sterile salt water), apply triple antibiotic ointment, cover with border foam, and change the dressing every two days and as needed. Staff was to discontinue the current treatments to the resident's right lateral malleolus (outside part of the ankle) and to her right buttock. There was no documented evidence that CRNP 4's February 13, 2023, progress note for Resident 78 was part of the clinical record.
Interview with Registered Nurse 1 and the Director of Nursing on May 17, 2023, at 1:15 p.m. confirmed that CRNP 4's note for Resident 78 from February 6, 2023, did not include his assessment of the resident's coccyx wound and that there was no documented evidence of his note from February 13, 2023, in the resident's clinical record.
Interview with the Director of Nursing on May 18, 2023, at 2:50 p.m. revealed that he had the physician's office fax over Resident 78's February 13, 2023, note from CRNP 4 today.
28 Pa. Code 211.5(f) Clinical records.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected 1 resident
Based on a list of nurse aides provided by the facility and their personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluat...
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Based on a list of nurse aides provided by the facility and their personnel files, as well as staff interviews, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed annually based on the hire dates for one of four nurse aides reviewed (Nurse Aide 3).
Findings include:
A review of the personnel file for Nurse Aide 3 revealed a hire date of January 11, 2007, with performance evaluations completed on January 12, 2023, and January 26, 2023. However, there was no documented evidence that her annual performance evaluation was completed as required in January 2022.
Interview with the Director of Human Services on May 17, 2023, at 1:55 p.m. confirmed that there was no documented evidence that Nurse Aide 3 had an annual performance evaluation completed as required in January 2022.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(e)(1) Management.
28 Pa. Code 201.20(a)(c) Staff development.
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 facility 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...
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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 maintain accountability for controlled medications (drugs with the potential to be abused) for two of 38 residents reviewed (Residents 22, 80).
Findings include:
A facility policy for medication dispensing, dated January 13, 2023, indicated that controlled drugs are documented as given at the time of administration as specified by federal and state regulations.
A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 22, dated May 2, 2023, revealed that the resident was cognitively intact, required extensive assistance with daily care needs, and had diagnosis of pain.
Physician's orders for Resident 22, dated February 13, 2023, included orders for the resident to receive one 5-325 milligrams (mg) tablet of Hydrocodone-Acetaminophen (a controlled narcotic pain medication) every six hours as needed for severe pain.
Review of Resident 22's controlled drug record (a form used to account for each dose of a controlled medication) for April 2023 revealed that one 5-325 mg tablet of Hydrocodone-Acetaminophen was signed-out by staff for administration to the resident on April 3, 7, 13, 14, 26, and 30, 2023. However, there was no documented evidence in the resident's clinical record, including on the Medication Administration Record (MAR), to indicate that staff actually administered the medication or that the medication was destroyed for any reason.
Physician's orders for Resident 22, dated January 31, 2023, included orders for the resident to receive a 12 microgram (mcg) per hour Fentanyl patch (a controlled narcotic pain medication) transdermally every three days for chronic pain, and an order to have a witness signature the disposal of the Fentanyl patch every three days.
Review of the controlled drug record for Resident 22 for April 2023 revealed that one 12 mcg per hour Fentanyl patch was signed out by staff for administration to the resident on April 1, 7, 10, and 13, 2023. However, there was no documented evidence in the resident's clinical record, including on the MAR, that there was a witness signature when the Fentanyl patch was disposed of.
Interview with the Nursing Home Administrator on May 17, 2023, at 2:44 p.m. confirmed that there was no documented evidence that doses of Hydrocodone-Acetaminophen were actually administered to Resident 22 and no documented evidence of a witness signature when the Fentanyl patch was disposed of.
A quarterly MDS for Resident 80, dated February 22, 2023, revealed that the resident was cognitively intact, required supervision with daily care needs, and had diagnoses that included diabetes.
Physician's orders for Resident 80, dated April 12, 2023, included an order for the resident to receive 0.5 milligrams (mg) of Clonazepam (a controlled drug) every six hours as needed for anxiety.
Review of the controlled drug record for Resident 80 for April 2023 indicated that a Clonazepam dose was signed out by staff on April 14, 2023, at 8:10 a.m.; April 18, 2023, at 8:00 a.m.; April 24, 2023, at 8:08 a.m.; and April 30, 2023, at 7:55 p.m. However, the resident's clinical record, including the MAR and nursing notes, contained no documented evidence that the signed-out doses of Clonazepam were administered to the resident on these dates and times.
Interview with the Nursing Home Administrator on May 18, 2023, at 11:00 a.m. confirmed that there was no documented evidence in Resident 80's clinical records to indicate that the signed-out doses of Clonazepam mentioned above were administered to the resident.
28 Pa. Code 211.9(h) Pharmacy services.
28 Pa. Code 211.12(d)(1) Nursing services.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on facility policy and CMS (Centers for Medicare & Medicaid Services) guidelines, as well as clinical record reviews and staff interviews, it was determined that the facility failed to ensure th...
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Based on facility policy and CMS (Centers for Medicare & Medicaid Services) guidelines, as well as clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents were free from unnecessary medications for one of 38 residents reviewed (Resident 80).
Findings include:
A facility policy for Psychotropic Drug Use, dated January 3, 2023, included that dosage reductions of anxiolytics (used to reduce anxiety) are attempted per CMS guidelines unless clinically contraindicated.
CMS guidelines include the Code for Federal Regulations (CFR) 483.45(e)(4) that as-needed orders for psychotropic (cause changes in mood and behavior; includes anxiolytics) drugs are limited to 14 days. Except as provided in CFR 483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the as-needed order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the as-needed order.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 80, dated February 22, 2023, revealed that the resident was cognitively intact, required supervision with daily care needs, and had diagnosis that included diabetes and anxiety.
Physician's orders for Resident 80, dated April 12, 2023, included that the resident receive 0.5 milligrams (mg) of Clonazepam (an anxiolytic) every six hours as needed for anxiety until end of life.
A review of clinical records, including physician progress notes for Resident 80, revealed no documented rationale for the long-term use of Clonazepam as needed, as required by federal law.
An interview with the Director of Nursing on May 17, 2023, at 11:18 a.m. confirmed that there was no documented rationale for the long-term use of as-needed clonazepam by the attending physician or by a psychiatric consultant.
28 Pa. Code 211.12(d)(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 and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to ...
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Based on review of the facility's plans of correction 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 a State Survey and Certification (Department of Health) survey ending May 25, 2022, 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 May 18, 2023, identified repeated deficiencies regarding accident hazards, nurse aide performance reviews, significant medication errors, infection control, and influenza and pneumococcal vaccines.
The facility's plan of correction for a deficiency regarding a failure to ensure that the resident environment remained free from accident hazards, cited during the survey ending May 25, 2022, revealed that the facility developed a plan 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 QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulations regarding accident hazards.
The facility's plan of correction for a deficiency regarding a failure to ensure ongoing compliance with the regulations regarding nurse aide performance reviews, cited during the survey ending May 25, 2022, revealed that the facility developed a plan 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 F730, revealed that the QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulations regarding nurse aide performance reviews.
The facility's plan of correction for a deficiency regarding a failure to ensure ongoing compliance with the regulations regarding significant medication errors, cited during the survey ending May 25, 2022, revealed that the facility developed a plan 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 F760 revealed that the QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulations regarding significant medication errors.
The facility's plan of correction for a deficiency regarding a failure to maintain an effective infection control program, cited during the survey ending May 25, 2022, 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 F880, revealed that the facility's QAPI committee failed to successfully implement their plans to ensure ongoing compliance with regulations regarding infection control.
The facility's plan of correction for a deficiency regarding a failure to ensure ongoing compliance with the regulations regarding influenza and pneumococcal vaccines, cited during the survey ending May 25, 2022, revealed that the facility developed a plan 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 F883, revealed that the QAPI committee failed to successfully implement their plan to ensure ongoing compliance with the regulations regarding influenza and pneumococcal vaccines.
Refer to F689, F730, F760, F880, F883.
28 Pa. Code 201.14(a) Responsibility of licensee.
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 guidance from the Centers for Disease Control (CDC-the national health protection agency) and clinical record review, as well as observations and staff interviews, it was determined...
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Based on review of guidance from the Centers for Disease Control (CDC-the national health protection agency) and clinical record review, as well as observations and staff interviews, it was determined that the facility failed to follow proper infection control policies related to urinary catheter care and failed to follow CDC guidelines to reduce the spread of infections and prevent cross-contamination related to Methicillin Resistant Staphylococcus Aureus (MRSA - a type of multidrug-resistant organism) infection for one of 38 residents reviewed (Resident 81).
Findings include:
CDC guidance on isolation precautions for MRSA residents contained in Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated July 12, 2022, indicates that multidrug-resistant organism (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. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with any of the following: Wounds or indwelling medical devices, regardless of MDRO colonization status and/or infection or colonization with an MDRO.
A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 81, dated April 12, 2023, revealed that the resident was sometimes understood and could sometimes understand others, required extensive assist for daily care needs, had an indwelling urinary catheter (a flexible tube that is inserted into the bladder to drain urine), and had diagnoses that included neurogenic bladder (lack of bladder control)
Physician's orders for Resident 81, dated May 12, 2023, included an order for the resident to receive 100 milligrams (mg) of Minocycline (an antibiotic) two times a day for ten days for MRSA in the left hip wound.
Observations on May 15, 2023, at 11:30 a.m. of Resident 81's room revealed a plastic cart containing personal protective equipment (PPE) beside the room entrance. An interview with Licensed Practical Nurse 7 at that time identified Resident 81 as having MRSA in a wound and confirmed that there was no sign on the resident's door advising staff and visitors of the need for precaution. An interview with the Director of Nursing at this time confirmed that the resident was in isolation for MRSA, and there should be a sign on the door advising precautions
Observations of Resident 81 on May 18, 2023, at 10:29 a.m. revealed that the resident was lying in bed with his urinary catheter bag lying on the floor. An interview with Registered Nurse 7 at that time confirmed that the resident's catheter bag was lying on the floor and should not have been.
Interview with the Infection Control Nurse on May 18, 2023, at 10:48 p.m. revealed that Resident 81 was being treated for a MRSA infection in his left hip wound, and that only standard precautions were required because his wound was contained in a clean dressing. She further revealed that the facility's policy is to use standard precautions for the care and treatment of an active MRSA infection and that contact precautions (including the use of gloves and gowns) were not required for any care, including care of a MRSA infected wound.
An interview with the Director of Nursing on May 18, 2023, at 2:52 p.m. revealed that his understanding of CDC recommendations is that contact isolation is not required for MRSA positive wounds if the wound is contained; therefore, contact isolation was not used.
28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management.
28 Pa. Code 211.10(d) Resident care policies.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
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 each resident was offered and/or received the influenz...
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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 each resident was offered and/or received the influenza immunizations for one of 38 residents reviewed (Residents 8).
Findings include:
The facility's policy regarding influenza (flu) vaccines, dated January 13, 2022, revealed that residents will be offered the flu vaccine annually between October 1 and March 31. The procedure for flu vaccines includes to obtain consent from the resident or legal representative, if indicated, obtain a physician's order, administer the vaccine, and document the administration on the Medication Administration Record (MAR).
An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated February 28, 2023, revealed that the resident was usually understood, could usually understand, and required extensive assistance from staff for his daily care tasks. Section O0250 A of the MDS (Influenza Vaccination) revealed that the resident did not receive the influenza vaccine in this facility for this year's influenza vaccination season due to being offered but declining the vaccine.
An informed consent for the influenza vaccine form for Resident 8, dated December 27, 2022, revealed that the resident gave consent to receive the influenza vaccine.
Review of the Medication Administration Records (MARs) for December 2022 through March 2023, as well as the clinical record for Resident 8, revealed no documented evidence that the resident received the influenza vaccine for the 2022-2023 flu season as requested.
Interview with the Nursing Home Administrator on May 17, 2023, at 9:29 a.m. confirmed that consent was obtained for Resident 8 to receive the flu vaccine; however, there was no documented evidence that the flu vaccine was administered.
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
(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
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident's respiratory status was properly monitored as o...
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Based on review of clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that a resident's respiratory status was properly monitored as ordered for one of 38 residents reviewed (Resident 17)
Findings include:
An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 6, 2023, revealed that the resident was understood and able to understand others, required extensive assist with daily care needs, received supplemental oxygen, and had diagnoses that included diabetes.
Physician's orders for Resident 17, dated February 7, 2023, included an order for the resident to receive continuous oxygen at five liters per minute, may adjust the oxygen to maintain saturations (the measure of how much oxygen is traveling through your body in your red blood cells) greater than or equal to 90 percent.
A review of Resident 17's vital sign records for February, March, April and May 2023 revealed no documented evidence that the resident's oxygen saturation was obtained to determine if she required her oxygen to be adjusted.
An interview with the Nursing Home Administrator on May 18, 2023, confirmed that Resident 17's oxygen saturation was not monitored as ordered.
28 Pa. Code 211.12(d)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected multiple residents
Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for two of 38 residents reviewed (Res...
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Based on review of clinical records and staff interviews, it was determined that the facility failed to ensure that it was free from significant medication errors for two of 38 residents reviewed (Residents 17, 77).
Findings include:
An Annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated April 6, 2023, revealed that the resident was understood and able to understand others, required extensive assist with daily care needs, had diagnoses that included diabetes (a disease that interferes with blood sugar control), and received insulin.
Physician's orders for Resident 17, dated May 4, 2021, included an order to check the resident's blood sugar before meals and at bedtime. Physician's orders, dated May 9, 2022, included an order for the resident to receive 3 units of Humalog (fast acting) insulin if her blood sugar is between 201 milligrams per deciliter (mg/dl) and 250 mg/dl, 6 units of Humalog insulin if her blood sugar is between 251 mg/dl and 300 mg/dl, 9 units of Humalog insulin if her blood sugar is between 301 mg/dl and 350 mg/dl, 12 units of Humalog insulin if her blood sugar is between 351 mg/dl and 400 mg/dl, and 16 units of Humalog insulin if her blood sugar is between 401 mg/dl and 450 mg/dl.
A review of the Medication Administration Records (MAR's) for Resident 17 for April and May 2023 revealed that the resident's blood sugar on April 5, 2023, at 4:30 p.m. was 211 mg/dl; on April 6, 2023, at 4:30 p.m. was 233 mg/dl; on April 8, 2023, at 4:30 p.m. was 227 mg/dl; on April 9, 2023, at 4:30 p.m. was 211 mg/dl; on April 14, 2023, at 11:30 a.m. was 300 mg/dl; on April 18, 2023, at 11:30 a.m. was 205 mg/dl; on April 23, 2023, at 4:30 p.m. was 234 mg/dl; on April 24, 2023, at 4:30 p.m. was 212 mg/dl; on April 26, 2023, at 11:30 a.m. was 313 mg/dl; on May 6, 2023, at 4:30 p.m. was 207 mg/dl; and on May 10, 2023, at 11:30 p.m. was 204 mg/dl. There was no documented evidence that the Humalog insulin was given for blood sugars greater than 200 mg/dl on these dates and times as ordered by the physician.
Interview with the Nursing Home Administer on May 18, 2023, at 12:11 p.m. confirmed that sliding scale Humalog insulin was not administered on the above-mentioned dates and time but should have been.
A quarterly MDS assessment for Resident 77, dated February 22, 2023, revealed that the resident was sometimes understood, could sometimes understand, and had diagnoses that included hypothyroidism (when the thyroid gland does not make enough thyroid hormones to meet your body's needs). A care plan for the resident, dated March 21, 2023, revealed that the resident had hypothyroidism and staff was not to change the resident's thyroid medications without consulting the endocrinologist (a doctor that treats diseases related to problems with hormones).
A nursing note for Resident 77, dated April 4, 2023, at 6:53 a.m. revealed that Certified Registered Nurse Practitioner 5 (CRNP - a registered nurse with advanced training and the authority to write orders for treatment) was in the facility and made aware of the resident's thyroid stimulating hormone (TSH - a blood test that measures this hormone) laboratory results. A new order was received to administer one 150 microgram (mcg) tablet of Levothyroxine (a medicine used to treat an underactive thyroid gland (hypothyroidism)) every morning and staff was to discontinue the administration of the 125 mcg tablet of Levothyroxine every morning.
A nursing note for Resident 77, dated April 4, 2023, at 10:43 a.m. revealed that per the endocrinologist the resident was to be administered one 175 mcg tablet of Levothyroxine every morning and staff was to discontinue the administration of the 150 mcg tablet of Levothyroxine every morning.
There was no documented evidence in Resident 77's clinical record that the 150 mcg dose of Levothyroxine was discontinued until April 16, 2023.
The medication administration records for Resident 77 for April 2023 revealed that staff administered the 150 mcg and the 175 mcg doses of Levothyroxine together on April 5, 6, 8, 11, 12, 13, and 15, 2023.
Interview with the Assistant Director of Nursing on May 18, 2023, at 10:45 a.m. confirmed that staff administered both the 150 mcg and the 175 mcg doses of Levothyroxine to Resident 77 on the above dates.
28 Pa. Code 211.12(d)(1)(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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 34% turnover. Below Pennsylvania's 48% average. Good staff retention means consistent care.
Concerns
- • 66 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $13,156 in fines. Above average for Pennsylvania. Some compliance problems on record.
- • Grade D (43/100). Below average facility with significant concerns.
Bottom line: Trust Score of 43/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Somerset Healthcare & Rehabilitation Center's CMS Rating?
CMS assigns SOMERSET 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 Somerset Healthcare & Rehabilitation Center Staffed?
CMS rates SOMERSET HEALTHCARE & REHABILITATION CENTER's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 34%, compared to the Pennsylvania average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Somerset Healthcare & Rehabilitation Center?
State health inspectors documented 66 deficiencies at SOMERSET HEALTHCARE & REHABILITATION CENTER during 2023 to 2025. These included: 1 that caused actual resident harm and 65 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Somerset Healthcare & Rehabilitation Center?
SOMERSET 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 ABRAHAM SMILOW, a chain that manages multiple nursing homes. With 120 certified beds and approximately 74 residents (about 62% occupancy), it is a mid-sized facility located in SOMERSET, Pennsylvania.
How Does Somerset Healthcare & Rehabilitation Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, SOMERSET HEALTHCARE & REHABILITATION CENTER's overall rating (2 stars) is below the state average of 3.0, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Somerset Healthcare & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Somerset Healthcare & Rehabilitation Center Safe?
Based on CMS inspection data, SOMERSET 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 Somerset Healthcare & Rehabilitation Center Stick Around?
SOMERSET HEALTHCARE & REHABILITATION CENTER has a staff turnover rate of 34%, which is about average for Pennsylvania nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Somerset Healthcare & Rehabilitation Center Ever Fined?
SOMERSET HEALTHCARE & REHABILITATION CENTER has been fined $13,156 across 1 penalty action. This is below the Pennsylvania average of $33,210. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Somerset Healthcare & Rehabilitation Center on Any Federal Watch List?
SOMERSET 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.