BRADFORD HILLS NURSING & REHABILITATION CENTER
For profit - Corporation
200 Beds
ALLAIRE HEALTH SERVICES
Data: November 2025
Trust Grade
15/100
#534 of 653 in PA
Last Inspection: November 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Bradford Hills Nursing & Rehabilitation Center has received a Trust Grade of F, indicating significant concerns and a poor level of care. It ranks #534 out of 653 facilities in Pennsylvania, placing it in the bottom half, and is the lowest-ranked in Bradford County. While the facility is improving-reducing issues from 24 in 2024 to 6 in 2025-there are still serious weaknesses, such as a serious incident where a resident was harmed by another resident, resulting in a femoral neck fracture. Staffing is average, with a turnover rate of 68%, which is concerning compared to the Pennsylvania average of 46%. Although there have been no fines recorded, the facility has reported issues like unsanitary food storage and pest problems in the kitchen, highlighting ongoing challenges that families should consider.
- Trust Score
- F
- In Pennsylvania
- #534/653
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 68% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Pennsylvania facilities.
- Skilled Nurses ○ Average
- Each resident gets 36 minutes of Registered Nurse (RN) attention daily — about average for Pennsylvania. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 55 deficiencies on record. Higher than average. Multiple issues found across inspections.
15/100
Bottom 19%
Review needed
24 → 6 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 24 issues
2025: 6 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
1-Star Overall Rating
Below Pennsylvania average (3.0)
Significant quality concerns identified by CMS
Staff Turnover: 68%
22pts above Pennsylvania avg (46%)
Frequent staff changes - ask about care continuity
Chain: ALLAIRE HEALTH SERVICES
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (68%)
20 points above Pennsylvania average of 48%
The Ugly 55 deficiencies on record
1 actual harm
Jun 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from ...
Read full inspector narrative →
Based on observation, staff interview, and review of facility documentation, it was determined that the facility failed to maintain an effective pest control program so that the facility is free from pests in the main kitchen area.
Findings include:
Observation of the facility's main kitchen on June 20, 2025, at 10:28 AM with Employee 1 (dietary clerk) and Employee 2 (dietitian) revealed the following:
The dishwashing area had multiple smaller winged insects flying around.
Two dead cockroach appearing insects were observed in the overhead wooden cupboards in the dishwashing area. These cupboards contained several loose unused trash bags and multiple boxes of surgical masks.
An opening between the wall splash guard and the underlying wall was observed. This opening was located under the stainless-steel counter in the dishwashing area. Further observation of this area revealed the plastic splash guard was not securely affixed to the wall as noted while pushing in the center of the splash guard. While tapping on the splash guard, there was obvious insect activity noted as evidenced by a cockroach appearing insect being observed just inside the opening to the area between the splash guard and wall.
Further observation revealed a thick, black colored, greasy, and sticky substance that coated the bottom of the stainless-steel table in the dishwashing area.
Observation of the cook area located on the opposite side of the kitchen from the dishwashing area revealed three dead cockroach appearing insects on the floor behind various cooking appliances. There was unidentified debris on the floor.
An interview with Employee 3, cook, on June 20, 2025, at 10:37 AM revealed sightings of cockroaches under the floor mats in the cook area in the morning.
Further observation of this area revealed four live cockroach appearing insects coming from underneath a wheeled cart against the wall (adjacent to the floor mats) that was used for storing clean pots and pans. There was also a dead cockroach appearing insect on the floor and an extensive build-up of dirt and debris along the perimeter of the wall.
Multiple air vents above a double set of egress doors to the kitchen contained a significant build-up of dust.
Pest control documentation dated June 3, 2025, revealed a visit for general pest control - maintenance. Targeted pests included cockroaches with bait applicators, aerosol, and compressed sprayer in the steamer motor compartment and baseboards in food prep with noted activity found on June 3, 2025, at 12:22 PM.
Pest control documentation dated June 10, 2025, revealed a visit for general pest control - maintenance. The pest control company noted the dishwashing area was inspected for cockroach activity and treated the problem area as needed. The documentation noted pest control staff followed up on the last visit with an inspection of the elevator, hallway, and dishwasher area for cockroach activity and found no activity, but treated all areas noted above to prevent future problems from occurring and to resolve any current issues.
The facility provided no further pest control documentation that the pest control service was notified of cockroach activity after their last visit.
An interview with the Director of Nursing on June 20, 2025, at 2:05 PM revealed the pest control company was contacted again today to advise of the surveyor findings and the pest control company will return this Saturday.
The facility failed to maintain an effective pest control program so that the facility is free of pests. There was no evidence that the facility sealed openings where pests can move or nest such as between the wall and splash guard in the dishwashing area, removed any dead insects, ensured a clean and sanitary environment (such as the floor and vents), and followed-up with staff to ensure current measures are effective at eradicating any pests.
The above information was reviewed in a meeting with the Director of Nursing and Employee 4 (Assistant Director of Nursing) on June 20, 2025, at 2:15 PM.
28 Pa Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(3) Management
May 2025
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, clinical record review, and resident and staff interview, it was d...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, clinical record review, and resident and staff interview, it was determined that the facility failed to ensure dependent residents received bathing assistance for four of six residents reviewed (Residents 1, 3, 4, and 6).
Findings include:
The facility policy entitled, Preferences Requests Policy, issued December 1, 2024, revealed that it is the nursing staff's responsibility to obtain a resident's bathing preferences (such as shower or bath, morning or afternoon, and how many times a week).
Clinical record review for Resident 1 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated March 20, 2025, that assessed him as being dependent upon staff for shower/bathing assistance.
Review of electronic task documentation dated April and May 2025, revealed that facility staff determined Resident 1's preference was to receive a shower one time a week in the evening. Review of the task documentation for bathing revealed that staff failed to document assistance with Resident 1's shower between April 23, 2025, to May 7, 2025. During this period, Resident 1 missed a shower on April 30, 2025. The documentation did not indicate that Resident 1 refused a shower.
Clinical record review for Resident 3 revealed an annual MDS dated [DATE], that determined Resident 3 required setup and/or clean up assistance with bathing.
Review of electronic task documentation dated April and May 2025, revealed that facility staff determined Resident 3's preference was to receive a shower one time a week in the morning. Review of the task documentation for bathing revealed that staff failed to document assistance with Resident 3's shower between April 21, 2025, to May 12, 2025. During this period, Resident 3 missed a shower on April 28, 2025, and May 5, 2025. The documentation did not indicate that Resident 3 refused a shower.
Interview with Resident 3 on May 13, 2025, at 1:05 PM revealed that he was to receive staff assistance with showering weekly, on Mondays; however, once in a while they ain't got enough staff.
Clinical record review for Resident 4 revealed a quarterly MDS dated [DATE], that assessed Resident 4 required partial to moderate staff assistance for showering/bathing.
Review of electronic task documentation dated April and May 2025, revealed that facility staff determined Resident 4's preference was to receive a shower one time a week in the evening. Review of the task documentation for bathing revealed that staff failed to document assistance with Resident 4's shower between April 21, 2025, to May 5, 2025. During this period, Resident 4 missed a shower on April 28, 2025. The documentation did not indicate that Resident 4 refused a shower.
Clinical record review for Resident 6 revealed a quarterly MDS dated [DATE], that assessed Resident 6 as dependent on staff for showering/bathing.
Review of electronic task documentation dated April and May 2025, revealed that facility staff determined Resident 6's preference was to receive a shower two times a week in the evening. Review of the task documentation for bathing revealed that staff documented the provision of a shower for Resident 6 weekly (April 18 and 25, 2025; and May 2 and 9, 2025), not twice a week as per Resident 6's preference. The documentation did not indicate that Resident 6 refused a shower.
Interview with Resident 6 on May 13, 2025, at 1:20 PM confirmed that she prefers a shower twice a week, especially in the summer.
The surveyor reviewed the above findings regarding Residents 1, 3, 4, and 6, during an interview with the Nursing Home Administrator and the Director of Nursing on May 13, 2025, at 1:36 PM.
28 Pa. Code 211.12(d)(1)(5) Nursing services
Mar 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
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, closed clinical record review, and staff interview, it was determi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, closed clinical record review, and staff interview, it was determined that the facility failed to implement procedures to exercise reasonable care for the protection of residents' property from loss for three of five residents reviewed (Residents CR1, CR3, and CR4).
Findings include:
The facility policy entitled, Personal Property, last reviewed/revised [DATE], revealed that a documented inventory of all residents' personal belongings will be completed upon admission by the nursing department, or another department identified by the facility. The inventory sheet will be updated when new items are acquired if the facility has been notified by the responsible party. The resident's personal belongings and clothing will be inventoried and documented upon admission and as such items are replenished. Missing items should be reported immediately to a staff member on the unit and placed on a concern/grievance form with follow through based on the concern grievance policy. The facility will promptly investigate any complaints of misappropriation or mistreatment of resident property. Personal belongings will be sent home with the resident upon discharge or within 30 days of discharge.
Closed clinical record review for Resident CR1 revealed that the facility admitted him on [DATE].
A Disposition of Resident's Personal Effects form revealed that the facility inventoried items (e.g., wallet, dentures, and glasses); however, did not inventory clothing on this form. Items noted as acquired after Resident CR1's original admission included a phone (without description of type) and charger. Resident CR1 signed this form on [DATE].
Interview with the Director of Nursing on [DATE], at 12:15 PM revealed that the facility does not record personal clothing on the Disposition of Resident's Personal Effects form; but sends all clothing to the laundry department who inventories the clothing and begins a different form. Only the laundry staff sign this form. The resident/responsible party do not acknowledge the accuracy of the inventory.
An untitled graph form provided by the facility with Resident CR1's name inventoried several items of clothing. The form was signed by staff; however, this form was not dated until [DATE] (more than a month after Resident CR1's admission to the facility).
Nursing documentation dated February 18, 2025, at 8:09 AM revealed that Resident CR1 experienced mental status changes, staff contacted his physician, and the physician provided an order to send Resident CR1 to the emergency department for evaluation.
Nursing documentation dated February 18, 2025, at 9:52 PM revealed that the emergency department admitted Resident CR1 to the hospital.
Review of Resident CR1's census information revealed that the facility discharged him on February 22, 2025.
Resident CR1's closed clinical record contained no documentation as to the disposition of Resident CR1's property. Neither Resident CR1 or his representative signed the Disposition of Resident's Personal Effects form after his discharge from the facility.
A Resident Grievance/Complaint form dated [DATE], at 1:00 PM indicated that Resident CR1 was missing his phone.
Interview with the Director of Nursing on [DATE], at 12:15 PM revealed that the Director of Nursing interviewed a nurse aide who stated that Resident CR1's responsible party picked up Resident CR1's personal property. Resident CR1's responsible party later reported that Resident CR1's phone was unaccounted for. The Director of Nursing confirmed that no staff had Resident CR1's responsible party attest to the collection of his property on discharge, there was no date when she came, and no progress note in the closed clinical record.
Closed clinical record review for Resident CR3 revealed that the facility admitted him on [DATE]. A Disposition of Resident's Personal Effects dated [DATE], indicated that Resident CR3 had no property (e.g., clothing).
An untitled graph form provided by the facility with Resident CR3's name inventoried several items of clothing. The form was signed by staff; however, this form was not dated until [DATE] (four days after Resident CR3's admission to the facility). Neither Resident CR3 or his representative attested to the accuracy of the clothing inventory.
Census information for Resident CR3 revealed that the facility discharged him on [DATE].
A late entry progress note created by the registered nurse the next day on [DATE], at 7:28 AM revealed that Resident CR3's family arrived for his discharge. The documentation indicated that Resident CR3 stated that he had all his belongings.
Resident CR3's closed clinical record did not contain evidence that Resident CR3, or his representative signed the Disposition of Resident's Personal Effects form upon his discharge.
Interview with the Director of Nursing on [DATE], at 2:10 PM confirmed the above findings for Resident CR3.
Closed clinical record review for Resident CR4 revealed that the facility admitted him on February 12, 2025. Nursing documentation dated February 12, 2025, at 3:19 PM indicated that the transport company left Resident CR4's belongings in the facility's reception area.
Resident CR4's closed clinical record contained no evidence that staff inventoried Resident CR4's property on a Disposition of Resident's Personal Effects form.
Nursing documentation dated February 23, 2025, at 10:09 PM revealed that Resident CR4 expired at the facility.
Documentation by the Nursing Home Administrator dated February 24, 2025, at 12:52 PM revealed that the writer received a telephone call from Resident CR4's responsible party that she would be at the facility to pick up Resident CR4's belongings. The same documentation indicated that Resident CR4's sister confirmed that she received all his belongings that included pictures in his room.
Resident CR4's closed clinical record contained no evidence that staff inventoried Resident CR4's property upon his discharge or that staff or Resident CR4's responsible party signed a Disposition of Resident's Personal Effects form.
Interview with the Director of Nursing on [DATE], at 2:27 PM confirmed the above findings for Resident CR4.
483.10(i)(1)-(7) Safe/clean/comfortable/homelike Environment
Previously cited deficiency [DATE]
28 Pa. Code 201.18(b)(2)(e)(1) Management
28 Pa. Code 201.24(e)(5) admission policy
28 Pa. Code 211.12(d)(3) Nursing services
Feb 2025
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0678
(Tag F0678)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, closed clinical record review, review of personnel certifications,...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of select facility policies and procedures, closed clinical record review, review of personnel certifications, and staff interview, it was determined that the facility failed to ensure properly certified personnel provided basic life support, including cardiopulmonary resuscitation (CPR), to a resident who required emergency care (Employee 1; Resident CR2).
Findings include:
Review of the facility policy POLST (Physician Orders for Life Sustaining Treatment, form used to document a resident/responsible party wishes in the event of a medical emergency such as the absence of a heart rate or respirations), last revised [DATE], revealed that the facility assists the resident/responsible family member (RP) in completing a POLST upon admission. If the resident/responsible family member is not ready to complete the POLST, the facility informs the resident/RP that until a decision is made, the resident will be considered a Full Code (CPR, medical intervention such as chest compression and artificial breaths to restore circulatory and/or respiratory function that has ceased, is provided). The resident will receive all resuscitation efforts.
Review of the facility policy, CPR: Defibrillation, last revised [DATE], revealed that defibrillation (use of an electrical current to help your heart return to a normal rhythm sometimes provided by an AED (automated external defibrillator) machine) is the most effective treatment for ventricular fibrillation (rapid, unsynchronized, contractions of the heart that can cause cardiac arrest and sudden death; requires immediate CPR and AED). The success of resuscitation of patients with ventricular fibrillation relates to how fast electrical defibrillation can be applied. The longer the duration of fibrillation, the greater the deterioration of the myocardium (heart muscle) because a fibrillating heart consumes a very large amount of oxygen. The chance of successful defibrillation is reduced as the fibrillation time increases. The procedural steps include:
Call a code green, call 911, and notify the physician stat (immediately)
Initiate CPR until the defibrillator is available
Prepare the resident for defibrillation
CPR continues until the defibrillator detects a change in the heart rhythm that may be shockable
Evaluate and maintain CAB (chest compression, airway, breathing) and continue CPR until an ambulance arrives with EMTs who provide relief, signs of life are observed, or a physician determines it should be stopped.
The facility policy entitled, Cardiopulmonary Resuscitation (CPR), last reviewed [DATE], stipulated that is the policy of the facility to adhere to residents' rights to formulate advance directives. In accordance with these rights, this facility will implement guidelines regarding cardiopulmonary resuscitation (CPR). Guidelines included that CPR certified staff will be available at all times, and staff will maintain current CPR certification for healthcare providers through a CPR provider who evaluates proper technique through in-person demonstration of skills. CPR certification, which includes an online knowledge component, yet still requires in-person skills demonstrations to obtain certification or recertification, is also acceptable.
Closed clinical record review for Resident CR2 revealed nursing documentation dated February 22, 2025, at 9:25 AM that Employee 1 (registered nurse supervisor) was called to Resident CR2's bathroom. Resident CR2 had decreased respirations to six (average normal range 12 to 20 breaths) and a thready, pulse of 45 (average normal range 60 to 100). The documentation indicated that the on-call physician was notified, and staff obtained an order to send Resident CR2 to the emergency room. Staff then noted that Resident CR2 was without a pulse and respirations. Staff called 911 (emergency medical personnel) and nursing staff started CPR. CPR continued until paramedics intubated (inserted a tube into the airway to perform artificial respirations) Resident CR2, started an intravenous line, and assumed ACLS (Advanced Cardiac Life Support, refers to a set of clinical interventions established by the American Heart Association (AHA) for the urgent and emergent treatment of life-threatening cardiovascular conditions). The paramedics obtained a physician's order to stop CPR and pronounce Resident CR2 deceased .
Order administration documentation dated February 22, 2025, at 9:35 AM revealed that Employee 2 (licensed practical nurse) noted that Resident CR2 was deceased at 9:25 AM.
A Code (CPR) Documentation form (document the facility utilized to record the sequence of events during a CPR event) dated February 22, 2025, for Resident CR2 revealed that Employee 1 recorded the sequence of events during Resident CR2's medical crisis on February 22, 2025. Employee 1 was the registered nurse in charge. Staff initiated CPR at 8:31 AM, and the AED was delivered at 8:45 AM. Comments documented on the form indicated that, Code called at 8:31 AM, CPR initiated at 8:31 AM, 911 activated at 8:31 AM, CPR continued, and paramedic and EMS arrived at 8:45 AM, AED applied, CPR continued.
The available documentation did not indicate that facility staff applied the AED to Resident CR2, but that the AED was applied after EMS personnel arrived.
Review of available facility personnel documentation for Employee 1 revealed that she completed the American Red Cross CPR/AED online training and was eligible for the skills session within 90 days; however, there was no indication that she completed the skills portion of the training to obtain her certification.
Interview with the Nursing Home Administrator on February 25, 2025, at 3:02 PM confirmed that Employee 1 did not have CPR/AED certification. The interview with the Nursing Home Administrator indicated that the facility had an AED machine on each of the three floors of the building. The facility did not provide evidence that facility staff, not EMS personnel, applied the AED timely to Resident CR2.
Telephone interview with the Nursing Home Administrator on February 26, 2025, at 9:35 AM confirmed the above findings.
The facility failed to ensure that licensed nursing staff maintained current CPR certification for healthcare providers through a CPR provider whose training included hands-on practice and in-person skills assessment.
201.19(3) Personnel policies and procedures
201.20(a)(1)-(6) Staff development
28 Pa. Code 211.12(d)(1)(5) Nursing services
Feb 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure self-dete...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and resident interview, it was determined that the facility failed to ensure self-determination for resident's choices related to shower preference for bathing for one of four residents reviewed (Resident 1).
Findings include:
A review of the census revealed that Resident 1 was admitted to the facility on [DATE].
An interview with Resident 1 on February 18, 2025, at 12:20 PM revealed that the resident stated that he had not received a shower since arrival in the facility and he and staff utilize wipes to bathe him.
Clinical record review for Resident 1 revealed an admission Minimum Data Set Assessment (MDS, an assessment completed at specific intervals to determine care needs) dated January 8, 2025, that noted facility staff assessed the resident as having a BIMS (Brief Interview for Mental Status) of 14, which indicated no cognitive impairment. The MDS revealed that the resident was dependent on staff for bathing. Further review of the MDS noted that the resident indicated that choosing between a tub bath, shower, bed bath, or sponge bath, was somewhat important.
Review of the current care plan for Resident 1 revealed an activities of daily living (ADL) self-care deficit. The care plan noted that the resident is total dependence on staff for bathing and listed an intervention as a Shower Tuesday and Saturday during the day.
Nursing documentation dated January 7, 2025, at 7:44 AM noted the resident prefers a shower Tuesday and Saturday.
The task list (located in the electronic health record where staff document specific care related events for a resident) for Resident 1 indicated shower/bath on Tuesdays/Saturdays and the resident's preference is a shower.
A review of the task list for Resident 1 for the last 30 days revealed staff documented the resident as receiving a Bed/Towel Bath on the following dates:
January 21, 2025, at 5:23 AM
January 23, 2025, at 3:29 PM
January 25, 2025, at 3:29 PM
January 26, 2025, at 3:29 PM
February 2, 2025, at 2:42 PM
February 6, 2025, at 10:51 PM
February 9, 2025, at 2:56 PM
February 17, 2025, at 11:29 PM
There were no showers given, as per resident preference, documented under the task list.
Further review of the clinical record revealed no evidence was documented to indicate Resident 1 refused a shower, there was a wound preventing a shower, an injury preventing a shower, or any other rationale.
An interview with the Director of Nursing on February 18, 2025, at 2:05 PM revealed that the facility could not provide any evidence why Resident 1's preference for a shower was not honored.
The Nursing Home Administrator and Director of Nursing were informed of the above findings on February 18, 2025, at 3:45 PM.
28 Pa. Code 201.29 (a) Resident rights
28 Pa. Code 211.12 (d)(5) Nursing services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure complete...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for one of seven residents reviewed (Resident CR1).
Findings include:
Closed clinical record review for Resident CR1 revealed the resident was admitted to the facility on [DATE], at 4:30 PM and signed out of the facility against medical advice on January 26, 2025, at 9:13 PM.
Closed clinical record review for Resident CR1 revealed a diagnosis list that included Type Two Diabetes Mellitus (a condition where the body cannot properly regulate blood sugar which results in an abnormally high blood sugar levels).
Clinical record review for Resident CR1 revealed a physician's order on the Medication Administration Record and Treatment Administration Record (MAR/TAR where staff document the administration of medications and treatments) dated January 26, 2025, at 9:00 AM that instructed staff to obtain a blood sugar four times a day for diabetes monitoring. Further review of the MAR/TAR revealed that staff documented with a checkmark (which indicated completed) on January 26, 2025, at 9:00 AM, 12:00 PM, and 5:00 PM. However, there were no values noted.
Facility documentation titled Weights and Vitals Summary, noted a blood sugar documented as 210 mg/dL(milligrams per deciliter) on January 26, 2025, at 6:15 PM. However, the facility could not provide any evidence of the values of the other two blood sugars that were documented as obtained.
An interview with the Nursing Home Administrator on February 18, 2025, at 12:15 PM revealed that the facility could not provide documentation on the additional two missing blood sugar values that were documented as obtained.
An interview with Employee 1, licensed practical nurse, on February 18, 2025, at 12:32 PM revealed Employee 1 had documented the blood sugars as measured, which was indicated with a checkmark on the MAR/TAR at the specified times in the electronic health record. However, was unable to pull up the values of the missing blood sugar measurements that Employee 1 also stated were entered at the specified times.
The facility failed to ensure a complete and accurate clinical record for Resident CR1.
The Nursing Home Administrator and Director of Nursing were informed of the above on February 18, 2025, at 3:45 PM.
28 Pa. Code 211.5(f) Medical records
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Nov 2024
20 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to protect a resident's right to...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to protect a resident's right to be free from physical abuse from another resident that resulted in actual harm with a serious injury of a left femoral neck fracture for one of two residents reviewed for resident-to-resident interactions. (Resident 399 [Resident 90], Unit 1 East).
Findings include:
Clinical record review for Resident 399 revealed that she was admitted to the facility on [DATE], with a diagnosis of Alzheimer's Disease (a progressive disease that destroys memory and other mental functions related to brain cell connections and the cells degenerate and die).
Clinical record review for Resident 399 revealed a progress note dated October 24, 2024, at 2:02 PM that indicated a nurse aide witnessed Resident 399 get kicked in the right side and she was threatened by Resident 90. Resident 399 was immediately removed from the room to the lounge area. Resident 90 was interviewed as to what happened and she indicated that she was defending herself.
Further clinical record review for Resident 399 revealed a nursing progress note dated October 24, 2024, at 2:43 PM that indicated she was kicked in her right torso by Resident 90. No injuries were noted to the resident, and she denied complaints of pain or discomfort. The note also indicated that Resident 399 had no recollection of the event.
Review of the facility's investigation into the Resident-to-Resident event involving Resident 399 and Resident 90, dated October 24, 2024, at 1:35 PM revealed that the two residents were separated, and 15-minute checks were initiated. Review of the 15-minute check monitoring form provided by the facility revealed that they were completed and have been ongoing since the event of October 24, 2024.
Review of the witness statement provided by the nurse aide that reported the above noted event revealed that she was walking by Resident 399 and Resident 90's room when she heard screaming. She stopped and went into the room, and she noted Resident 399 was on Resident 90's side of the room confused and stated that she needed help getting her daughter out of the wall because she was stuck. At that time Resident 90 kicked Resident 399 in the right side and said that she was going to kill her if she didn't leave her alone. The nurse aide provided reassurance to Resident 399 as she led her out of the room. The nurse aide also indicated in her statement that Resident 90 continued to kick at Resident 399 and tell her she was going to kill her if she came back into the room.
Further clinical record review for Resident 90 revealed a physician's order dated October 24, 2024, that indicated she was to be one-to-one every shift for monitoring. The order was discontinued on November 9, 2024. When the surveyor requested documentation of the one-to-one monitoring for Resident 90, on November 22, 2024, at 12:30 PM the Nursing Home Administrator (NHA) revealed that they had initiated one-to-one on October 24, 2024, but she verbally discontinued it with the RN supervisor later that evening because Resident 90 calmed down. She also indicated that 15-minute checks remained in place and were being completed.
Clinical record review for Resident 90 revealed a progress note dated October 25, 2024, at 4:04 PM that indicated Resident 90 was being combative and trying to attack Resident 399 and staff. The note also indicated that Resident 90 would not get off Resident 399's bed and indicated that Resident 90 was going to slap Resident 399 and break her television.
A progress note dated October 25, 2024, at 4:41 PM for Resident 90 revealed that she was becoming increasingly physically and verbally aggressive. She hit a staff member in the face and was refusing medications. She was stating that everyone is attempting to poison her. The physician was made aware, and Resident 90 was sent to the emergency room for a psych evaluation and treatment. Resident 90 returned from the emergency room on October 26, 2024, around 5:00 AM, with no new orders. She remained in the same room with Resident 399, upon her return, with the same resident that she kicked two days earlier, and continued to threaten to kill her, slap her, and break her television
Clinical record review for Resident 399 revealed a progress note date October 27, 2024, at 10:00 PM that indicated she was observed on the floor just inside her room. She complained of left hip pain and was reluctant to straighten her left leg. Her left leg was also noted to be shorter in length. The nurse practitioner was notified and ordered for Resident 399 to go to the emergency room for an evaluation.
Further clinical record review for Resident 399 revealed a progress note dated October 28, 2024, at 12:39 AM that indicated she was admitted to the hospital with a comminuted intertrochanteric fracture of the left femoral neck (a bone broken in multiple pieces in the area of the femur that connects the ball joint to the shaft of the thigh bone).
Review of the facility's investigation into Resident 399's fall revealed a witness statement that indicated the staff member was walking down the hallway and heard Resident 90 say, Bitch, so she went into the room. She noted that Resident 399 was on the floor complaining of pain and Resident 90 was lying in bed. When the witness asked Resident 399 what happened, Resident 90 interjected and stated she picked her up and threw her to the ground because she was attacking her. Resident 90 had no injuries when assessed.
Review of the facility reported event dated October 27, 2024, at 9:27 pm revealed that Resident 399 indicated that she was coming out of the bathroom and Resident 90 pushed her and she fell. The event indicated that Resident 90 was unprovoked.
Clinical record review for Resident 90 revealed an MDS (Minimum Data Set, an assessment completed at intervals by the facility to determine care needs) quarterly assessment that revealed Resident 90 had a BIMS (Brief interview for mental status, an assessment to determine a resident's cognitive status) of 13, indicating she was cognitively intact.
On October 27, 2024, Resident 399 had a fall in her room and Resident 90 admitted to throwing her to the ground. The actions by Resident 90, resulted in a fracture to Resident 399's left femoral head requiring hospital admission and intervention.
The NHA was made aware of the concerns related to resident-to-resident abuse on November 22, 2024, at 2:39 PM and the failure of the facility to initiate further interventions (i.e., a room move, use of outside resources, etc.) to prevent resident-to-resident abuse resulting in a major injury to Resident 399.
The facility failed to protect Resident 399's right to be free from physical abuse by another resident resulting in actual harm to Resident 399, of a left femoral neck fracture.
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18 (b)(1)(2)(e)(1) Management
28 Pa. Code 201.19(6)(7)(8) Personnel policies and procedures
28 Pa. Code 201.20(b)(d) Staff development
28 Pa. Code 201.29 (a)(c) Resident rights
28 Pa. Code 211.12(c)(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 F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on observations and resident and staff interview, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to the...
Read full inspector narrative →
Based on observations and resident and staff interview, it was determined that the facility failed to ensure that residents could make choices about aspects of their lives that were significant to them, such as rising for the day, for one of four residents reviewed (Resident 108).
Findings include:
Clinical record review for Resident 108 revealed an initial MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated May 26, 2024, that indicated Resident 108 believed that it was very important to care for her personal belongings, choose between a bed bath, shower, or a sponge bath, choose the clothes to wear, to have snacks available between meals, and choose a bedtime, and have a family member or close friend involved in care discussion(s).
Interview with Resident 108 on November 19, 2024, at 10:41 AM revealed that she preferred to get up at 7:00 AM and go to bed between 7:00 PM and 7:30 PM. She revealed that there were some days when she was still in bed at 12:00 PM and did not get to bed until 9:00 PM or 9:30 PM, due to late supper meal delivery (7:00 PM) most nights.
Observation on November 20, 2024, at 10:40 AM revealed that Resident 108 was still in bed. She again reiterated her preference of getting up for the day between 7:00 AM and 7:30 AM.
The surveyor reviewed the information for Resident 108 during an interview with the Nursing Home Administrator and the Director of Nursing on November 20, 2024, at 1:45 PM.
28 Pa Code: 201.29(a) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to establish clear advance direc...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to establish clear advance directives for one of five residents reviewed (Resident 15).
Findings include:
A review of the census for Resident 15 revealed the resident was admitted to the facility on [DATE].
Current physician orders for Resident 15 revealed an order dated [DATE], that indicated the resident was a Full Code (attempt resuscitation and CPR when the person has no pulse and is not breathing).
Nursing documentation for Resident 15 dated [DATE], at 1:19 PM revealed the resident is a full code.
Facility documentation titled, Code Status for Resident 15 and dated [DATE], indicated the resident was marked with a check indicating Do Not Resuscitate (do not attempt CPR when the person has no pulse and is not breathing).
The form was signed by Resident 15 and the medical provider and dated [DATE], by both.
The above discrepancy between the resident's signed wishes and the physician order was reviewed in a meeting with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on [DATE], at 2:35 PM.
Nursing documentation for Resident 15 dated [DATE], at 5:37 PM after speaking with the NHA and DON, revealed, Chart currently listed as full code; however, documentation signed on [DATE], indicates wishes to be DNR. After discussion the resident does wish to be a full code.
Further review of the orders for Resident 15 dated [DATE], revealed that staff entered the resident order as a DNR (do not attempt resuscitation and CPR when the person has no pulse and is not breathing).
The above information was reviewed again with the NHA and DON on [DATE], at 1:00 PM.
483.10(c)(6)(8)(g)(12)(i)-(v) Request/refuse/discontinue Treatment; Formulate Advance Directive
Previously cited deficiency [DATE]
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to implement their abuse policy regarding completion of an in...
Read full inspector narrative →
Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to implement their abuse policy regarding completion of an investigation of an unknown injury for one of six residents reviewed (Resident 118) and background check screening for one of five newly hired employees (Employee 4 ).
Findings include:
The policy entitled Resident Abuse and Neglect Prevention Program last reviewed on May 28, 2024, indicates that the facility will investigate bruises and/or marks of unknown origin. An incident/accident report will be initiated by the charge nurse and an investigation is initiated to rule out the possibility of abuse. The policy does not indicate how other injuries will be investigated to rule out abuse, such as fractures. The policy indicates to refer to the policy entitled Incident/Accident Investigative Reports. The policy indicates that the facility will conduct a criminal background check on all prospective staff utilizing the State Police and Federal Bureau of Investigation if required. The criminal background check will be completed within 30 days for State Police report.
The undated policy entitled Investigation of Incidents and Unusual Occurrences was received when this surveyor asked for the policy entitled Incident/Accident Investigative Reports. Review of this policy did not indicate how the facility will investigate injuries of unknown origin to rule out the potential for abuse.
Review of Resident 118's clinical record revealed nursing documentation dated October 7, 2024, at 6:35 AM indicating that Resident 118 was complaining of left rib pain. Nursing indicated that Resident 118's doctor would be notified.
Nursing documentation dated October 8, 2024, at 6:00 AM indicated that Resident 118 continued with complaints of left rib pain and was requesting an x-ray.
Nursing documentation dated October 8, 2024, at 12:25 PM revealed that an order for an x-ray was obtained from Resident 118's physician and that Resident 118 had a previous fall. There was no documented evidence in Resident 118's clinical record to indicate he had fallen prior to this injury.
Nursing documentation dated October 8, 2024, at 10:30 PM indicated that Resident 118's x-ray results showed a fracture of his left 10th rib.
Interview with the Administrator on November 21, 2024, at 1:22 PM confirmed that Resident 118 did not have any falls prior to October 11, 2024.
Interview with the Administrator on November 22, 2024, at 10:00 AM confirmed that the facility did not complete an investigation into Resident 118's fractured rib to rule out the potential for abuse and/or neglect.
Review of Employee 4's, licensed practical nurse, employee file reveled the facility hired Employee 4 on September 9, 2024. Employee 4 worked at the facility through October 18, 2024. There was no evidence a state police criminal background check was completed on the employee.
In an interview with the Nursing Home Administrator on November 21, 2024, at 2:15 PM the Administrator indicated Employee 4 had not worked at the facility since October 18, 2024, and that a state police criminal background check had not been completed as required.
483.12 (b) Development and Implementation of Abuse Policy
Previously cited 12/8/23
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.29(a)(c) Resident rights
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to identify the potential for, ensure a complete and thorough investi...
Read full inspector narrative →
Based on review of facility documentation, clinical record review, and staff interview, it was determined that the facility failed to identify the potential for, ensure a complete and thorough investigation of, and to ensure timely reporting of an incident involving the potential for neglect for one of 29 residents reviewed (Resident 65)
Findings include:
Clinical record review for Resident 65 revealed nursing documentation dated November 7, 2024, at 2:19 PM that indicated that staff was notified at 11:00 AM by Resident 65 that she had a fall. Resident 65 revealed that the fall occurred prior to the change of shift. She noted that she requested to be changed (receive incontinence care). The (nurse) aide came in and when I rolled to by side, I rolled out of the bed and landed on my knees. The (nurse) aide went and got another aide and helped me back into bed. Staff noted that Resident 65 was capable and sustained two small abrasions on both of Resident 65's knees and a scratch on her right elbow.
Review of Resident 65's care plan revealed that on June 17, 2024, the facility implemented that the resident required two (staff) assist to reposition and turn in bed.
Review of a facility's investigation dated October 7, 2024, confirmed the nursing documentation; however, failed to identify the staff member who rolled Resident 65 out of bed, failed to identify that Resident 65 needed to have two staff with bed mobility, and failed to report this potential for neglect to the appropriate state and local agencies. Review of Employee 9's, nurse aide, statement dated October 7, 2024, revealed that a (unidentified) nurse aide came to her office regarding the above noted incident with Resident 65. The nurse aide revealed that Resident 65 was crying and requested that Employee 9 go see Resident 65. The nurse aide noted that they rolled her out of bed, just put her back in bed, and she hurt all over. Employee 9 visited Resident 65 confirmed her statement noted in the nursing documentation stating the nurse aide was a little annoyed and rolled her right out of bed onto the floor, went out of the room, and returned with another aide. They lowered the bed, and it took several attempts to get her back into bed. Employee 9 reported this information to the Nursing Home Administrator (NHA), (prior) Director of Nursing (DON), and Assistant Director of Nursing.
Review of Employee 10's, nurse aide, statement received November 22, 2024, via a telephone call with the NHA, Employee 9, and the DON, revealed that a nurse aide had requested her help that night to get Resident 65 back to bed as Resident 65's bottom half had slid off the bed. Employee 10 assisted the nurse aide to get Resident 65 back into bed, noting, I did not realize she (the nurse aide) had not told anyone else (i.e., nursing staff).
There were no statements available from the nurse aide who rolled Resident 65 out of bed, no documentation that the facility identified the potential for neglect, and that the facility notified the appropriate State and Local agencies regarding the incident and potential for neglect.
This surveyor reviewed this information during an interview with the NHA and Director of Nursing on November 22, 2024, at 10:34 AM.
28 Pa. Code 201.14(a)(c) Responsibility of licensee
28 Pa. Code 201.18(b)(2)(e)(1) Management
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to en...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to ensure the availability of necessary emergency supplies for one of two residents reviewed receiving hemodialysis (Resident 52).
Findings include:
Clinical record review for Resident 52 revealed the resident was admitted to the facility on [DATE], and was receiving hemodialysis (a machine that performs a basic function of the kidney by cleansing the blood of impurities) three days a week.
A nursing progress note dated November 1, 2024, at 7:28 PM noted the resident had a right chest tunnel catheter (a central line placed under the skin allowing long term access to a vein) for dialysis.
An observation of Resident 52's room on November 20, 2024, at 10:25 AM did not reveal any emergency supplies in the resident 's room for the central line to include sterile gauze, hemostat (a tool used to control bleeding), needleless connector, or tape.
The above information regarding Resident 52's central line for dialysis and no evidence of an emergency kit in the resident's room was reviewed with the Nursing Home Administrator and Director of Nursing on November 20, 2024, at 2:42 PM. The Nursing Home Administrator indicated the kit may have been inside the resident's closet.
A concurrent observation with the Nursing Home Administrator revealed there was no kit in Resident 52's closet or otherwise observed in the resident's room.
483.25 (1) Dialysis
Previously cited 12/8/23
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
Based on clinical record review and resident and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, t...
Read full inspector narrative →
Based on clinical record review and resident and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care, and to eliminate or mitigate re-traumatization for one of four residents reviewed for mood/behavior (Resident 22).
Findings include:
Clinical record review revealed the facility admitted Resident 22 on November 2, 2015, with a diagnosis of Post Traumatic Stress Disorder (PTSD, a mental and behavioral disorder that develops related to a terrifying event).
Review of Resident 22's annual MDS (Minimum Data Set Assessment, an assessment completed at least quarterly by the facility to determine the care needs of the resident) dated June 15, 2024, revealed that she had an active diagnosis of PTSD.
Interview with Resident 22 on November 19, 2024, at 12:10 PM revealed that she has a diagnosis of PTSD and that she is triggered by people arguing and fighting, screaming, and doors slamming. She also indicated that she would pick at her fingernail beds and gets very anxious when she is triggered.
Review of Resident 22's clinical record revealed no evidence that the facility identified Resident 22's history of trauma. A review of Resident 22's care plan revealed there were no identified triggers (everyday situations that cause a person to re-experience the traumatic event as if it was reoccurring).
Resident 22's clinical record contained no evidence the facility collaborated with the resident, and as appropriate, the resident's family, friends, and any other healthcare professionals (such as psychologists, and mental health professionals) to develop and implement individualized interventions.
These findings were reviewed with the Nursing Home Administrator and Director of Nursing on November 21, 2024, at 2:30 PM.
28 Pa Code 211.12 (d)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure an appropriate physician response to the consultant pharmac...
Read full inspector narrative →
Based on clinical record review, review of facility documentation, and staff interview, it was determined that the facility failed to ensure an appropriate physician response to the consultant pharmacist's recommendation for one of five residents reviewed for potentially unnecessary medications (Resident 122).
Findings include:
Current physician orders for Resident 122 revealed an order for Oxycodone HCL (an opioid analgesic pain medication used to treat moderate to severe pain) dated September 10, 2024, that instructed staff to give one tablet by mouth every four hours as needed for moderate to severe pain (4-10) with a maximum daily amount of 30 milligrams (mg).
Further review of the current physician orders revealed an order for Resident 122 for Acetaminophen (Tylenol; used to treat mild to moderate pain and/or reduce fever) tablet dated September 10, 2024, that instructed staff to give 650 mg every four hours as needed for mild pain rated 1-3 and not to exceed 3000 mg in 24 hours.
A consultant pharmacist recommendation dated September 17, 2024, noted the following regarding Resident 122: This resident has orders for Tylenol as needed (a few times in the evening) and Oxycodone as needed (uses at bedtime almost every day). Recommendations: Tylenol XR 650 milligrams Arthritis one by mouth daily at 5:00 PM for pain management; Oxycodone 2.5 milligrams every bedtime for 14 days. The recommendation indicated a Note written to physician.
The note written to the physician for the above consultant pharmacist recommendation for Resident 122 was not provided to the surveyor by the facility.
An interview with the Nursing Home Administrator on November 21, 2024, at 1:50 PM revealed that the consultant pharmacist recommendation for Resident 122 was not completed and will be followed-up on today.
28 Pa. Code 211.2(d)(8) Physician services
28 Pa. Code 211.9(k) Pharmacy services
28 Pa. Code 211.12(d)(3)(5) Nursing services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, it was determined that the facility failed to ensure appropriate medication security on one of five nursing units (Resident 83, Second Floor East)
Findings in...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to ensure appropriate medication security on one of five nursing units (Resident 83, Second Floor East)
Findings include:
Observation of Resident 83 on November 19, 2024, at 2:20 PM revealed the resident was in bed. A bottle of iodine solution was observed sitting on the resident's tray table in front of her amongst many personal belongings.
A follow up observation on November 20, 2024, at 10:09 AM revealed the bottle was again observed on the resident's tray table in front of the resident in bed. The bottle was labeled Povidone-Iodine solution 10%. Resident 83 indicated she was applying it to a mole on her face and was to put it on daily, but she hasn't in a long time. Resident 83 indicated she purchased the solution herself, but they know about it, and that I have it.
Clinical record review revealed no evidence of any iodine solution ordered for Resident 83, any order to self- administer the solution, or store it in her room. Resident 83 resided in a room with a roommate.
In an interview with the Nursing Home Administrator and Director of Nursing on November 21, 2024, at 2:00 PM it was reviewed the iodine solution was in Resident 83's room, unsecured, and accessible to the resident to self-administer, and other residents on the unit.
483.45(h) Drug Storage
Previously cited 12/8/23, 10/31/24
28 Pa. Code 211.9(k) Pharmacy services
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected 1 resident
Based on observation, review of facility documentation, and resident and staff interview, it was determined that the facility failed to serve food at a palatable temperature on one of five nursing uni...
Read full inspector narrative →
Based on observation, review of facility documentation, and resident and staff interview, it was determined that the facility failed to serve food at a palatable temperature on one of five nursing units (Third Floor East, Resident 15).
Findings include:
Review of the Food Committee meeting minutes dated September 14, 2024, and October 17, 2024, noted that residents replied sometimes when asked if the hot food was hot and the cold food was cold.
Interview with Resident 15 on November 19, 2024, at 11:20 AM revealed concerns that sometimes the food was not hot and a little on the colder side.
Observation of meal service on the Third Floor East Nursing Unit on November 21, 2024, at 1:26 PM revealed that the food trays arrived on the unit and staff began immediately serving the meals. Further observation revealed that staff had passed the last resident food tray at 1:31 PM. The surveyor obtained a test tray at this time from the meal cart and began testing the food temperatures.
The oven fried chicken entrée was tested at 111.2 degrees Fahrenheit.
The plain white rice was tested at 119.2 degrees Fahrenheit.
The temperatures were confirmed by Employee 5, nurse aide, at the time of the testing.
Further observation at the time of testing revealed the food did not feel hot to the touch nor was any steam observed rising from the food items. The oven fried chicken and rice tasted lukewarm and was not hot.
The above information was reviewed with the Nursing Home Administrator on November 22, 2024, at 1:00 PM.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to im...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to implement appropriate enhanced barrier transmission-based precautions for three of 29 residents reviewed (Residents 52, 83, and 131).
Findings include:
Review of the memo entitled Enhanced Barrier Precautions (EBP, gown and glove use) in Nursing Homes to Prevent the Spread of Multi-drug Resistant Organisms released by the Center for Medicaid and Medicare Services (CMS) on March 20, 2024, with an implementation date of April 1, 2024, revealed that nursing care facilities are to use EBP for residents with chronic wounds or indwelling medical devices (i.e., indwelling urinary catheters) during high-contact resident care activities regardless of their multidrug-resistant organism status. High-contact activity would include things like dressing, transferring, changing linens, providing hygiene, changing briefs, wound care, or device care.
Review of the facility policy titled, Infection Control Plan 2024, last reviewed without changes on September 20, 2023, revealed a policy statement that noted an infection control plan is established and maintained to provide a safe, sanitary, and comfortable environment for residents and staff to help prevent the development and transmission of communicable diseases and infections within the facility. A section of the policy noted enhanced barrier precautions are an infection control intervention designed to reduce transmission of MDROs through gown and glove use by healthcare providers in long-term care settings. EBP recommended during high contact care (such as dressing, bathing, transferring, changing briefs, or assisting with toileting, device care, wound care, etc.) activities with residents who are at a higher risk of acquiring or spreading an MDRO (such as residents with indwelling medical devices or wounds). EBP should be followed when contact precautions do not otherwise apply for residents with any of the following: open wounds requiring a dressing change, indwelling medical devices (central line, urinary catheter, feeding tubes, tracheostomy/ventilator) regardless of the MDRO status.
Clinical record review for Resident 131 revealed a diagnosis list that included sepsis (a systemic response to infection) and resistance to multiple antimicrobial drugs.
Current physician orders for Resident 131 revealed an order dated November 19, 2024, that noted the resident was to receive Meropenem (an antibiotic) two grams intravenously every eight hours for sepsis related to a thigh abscess (a tender mass filled with pus caused due to infection). Another order dated November 10, 2024, instructed staff to change the PICC (peripherally inserted central catheter; a thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) dressing every day shift every Sunday.
Observation of Resident 131 on November 20, 2024, at 11:00 AM revealed the resident was sitting in a wheelchair at the foot of the bed. The resident had a PICC in the left arm. There was no observed EBPs in place or evidence of EBPs being utilized (signage indicating EBPs, personal protective equipment (PPE) such as gowns/gloves, or totes/bins containing PPE).
Clinical record review for Resident 131 revealed no further evidence the resident was on any isolation or EBPs.
Observation of Resident 131 on November 20, 2024, at 3:05 PM with the Nursing Home Administrator (NHA) confirmed the above findings that the resident had a PICC with no EBPs in place.
Clinical record review for Resident 52 revealed the resident was admitted to the facility on [DATE], and was receiving dialysis (a blood purifying treatment given when kidney function is not optimum) treatments three days a week via a central line in her right chest.
An observation of Resident 52's room on November 19, 2024, at 12:52 PM revealed the resident was in her room with a visitor. There was no evidence of any signage for EBP's, personal protective equipment bins, or supplies, such as gowns, or masks, in the room, on the door, or anywhere in the hallway near the resident's room.
An observation of Resident 83 on November 19, 2024, at 2:29 PM revealed the resident was in bed with a foley catheter in place. Upon interview the resident sated she has had the urinary catheter since her admission to the facility in 2022. There was no evidence to indicate Resident 83 had EBP's in place. There was no signage by the resident's room, and there was no evidence of additional personal protective equipment such as gowns or masks near the resident's room in the hallway or on the resident's door.
In an interview with the NHA and Director of Nursing on November 20, 2024, at 2:40 PM it was confirmed Resident 52 should have EBP's in place for a central line and Resident 83 due to her catheter.
Resident 52 and 83 received physician orders for the implementation of EBP's after the above interview.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on observation and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environ...
Read full inspector narrative →
Based on observation and staff and resident interview, it was determined that the facility failed to provide adequate housekeeping and maintenance services to ensure a clean, safe, and orderly environment on two of five nursing units (2E and 2W Nursing Units, Residents 15, 32, 73, 84, and 134).
Findings include:
Observation of the 2 E Nursing Unit on November 19, 2024, at 9:45 AM revealed that there was a damp odor upon entry to the unit's shower room.
Observation of the 2 W Nursing Unit on November 19, 2024, at 12:31 PM revealed that there was a damp odor and fecal material upon entry to the unit's shower room. There was a one-half tile piece missing and another tile that was cracked on the corner of the wall near the sink and entry door. On the lower part of the tiled wall and floor in the shower area, there was a black substance in the grout lines of the tile.
The surveyor reviewed the above information during an interview with the Nursing Home Administrator and Director of Nursing on November 20, 2024, at 1:45 PM.
Observation of Resident 15's room on November 19, 2024, at 11:18 AM revealed the following:
A large portion of the bathroom ceiling had pain peeling off it. Some paint flakes were observed hanging from at least two cobwebs.
The exhaust fan in the bathroom was making a loud, rattling-like noise when turned on which was in conjunction with the ceiling light. A concurrent interview with Resident 15 reported it has been like that since his admission to the facility on October 11, 2024.
The wall behind Resident 15's bed was marred with missing paint in several locations.
The privacy curtain had brown stains on it especially near the bottom of the curtain.
Observation of the room labeled Patient Lounge on the Two [NAME] Nursing Unit on November 19, 2024, at 1:30 PM and again on November 20, 2024, at 10:31 AM revealed the following:
A maroon colored Geri-chair labeled for Resident 73 had brown colored and dried stains on a black colored seat cushion. There was a significant build-up of crumbs and debris under the cushion. The bilateral arm rests had a build-up of a white colored, dry skin appearing substance.
An unlabeled flower pattern resident chair had a significant amount of debris under a pressure pad located on the seat of the chair. The perimeter of the seat cushion contained various debris and crumbs.
A wheelchair labeled for Resident 84 had a build-up of debris under the pressure cushion located on the seat. There was an additional black colored cushion on the seat that had significant fraying. The canvas storage area located on the rear of the back rest was almost completely torn down the left side and had multiple pieces of thread from the fabric hanging from the damaged section.
There was a yellow/red/gray colored striped chair with wooden arm rests and legs that had significant stains and dried liquid stains on the seat cushion of the chair.
Observations on November 20, 2024, at 10:31 AM, in addition to the above, included the following:
A light green colored Geri-chair labeled for Resident 134 had a pressure cushion located on the seat that contained multiple crumbs and debris. There was a brown colored, dried stain on the seat of the cushion. The bilateral arm cushions were frayed with the underlying foam visible.
A light green colored Geri-chair labeled for Resident 32 had a blue colored pad on top of a pressure cushion located on the seat that contained brown stains and strands of hair. The bilateral arm cushions were frayed with the underlying foam visible.
Employee 8, housekeeping staff, was informed of the above findings for the resident lounge on November 20, 2024, at 10:52 AM.
The Nursing Home Administrator and Director of Nursing were informed of the above findings for Resident 15 and the resident lounge on Two [NAME] Nursing Unit on November 20, 2024, at 2:15 PM.
28 Pa. Code 201.18(b)(3) Management
28 Pa. Code 207.2(a) Administrator's responsibility
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on observation and resident and staff interview, it was determined that the facility failed to ensure resident grievances were addressed timely for four of six residents (Residents 22, 24, 65, a...
Read full inspector narrative →
Based on observation and resident and staff interview, it was determined that the facility failed to ensure resident grievances were addressed timely for four of six residents (Residents 22, 24, 65, and 95 ).
Findings include:
Review of resident grievances revealed the following:
Resident 24 filed a grievance on August 6, 2024, and August 13, 2024.
Resident 95 filed a grievance on August 7, 2024.
Resident 65 filed a grievance regarding a concern on September 24, 2024.
There was no documentation available that the facility investigated and addressed Resident 24, 65, and 95's concerns until November 13, 2024.
The surveyor reviewed the above information during an interview with the Nursing Home Administrator and the Director of Nursing on November 20, 2024, at 1:45 PM.
Review of a grievance filed by Resident 22 on September 15, 2024, revealed that there was no evidence that the facility addressed the concern until November 13, 2024.
Interview with the Nursing Home Administrator on November 21, 2024, at 2:15 PM confirmed that Resident 22's grievance was not addressed in a timely manner.
28 Pa Code: 201.29(a) Resident rights
28 Pa Code: 201.29(b)(c) Resident rights
28 Pa Code: 201.18(e)(1) Management
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services identified to reduce a resident's decline in ADL's (activities of daily liv...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to provide care and services identified to reduce a resident's decline in ADL's (activities of daily living) for five of five residents reviewed (Residents 47, 66, 73, 80, and 108).
Findings include:
Clinical record review for Residents 47 revealed a current task for staff to provide:
nursing rehab for dressing and grooming, staff to encourage resident to assist with all dressing and grooming every shift
nursing rehab eating and swallowing, staff to encourage resident to eat 50 to 75 percent of all meals
Review of task documentation for Resident 47 revealed that staff did not document completion or documented NA (Not Applicable) of the nursing rehab grooming task on the following dates:
Day Shift:
October 7, 13, 24, and 27 2024
November 1, and 7, 2024
Evening Shift:
October 2, 5, 6, 12, 14, 16, 19, and 25, 2024
November 3 and 17, 2024
Review of task documentation for Resident 47 revealed that staff did not document completion or documented NA (Not Applicable) of the nursing rehab eating task on the following dates:
Day Shift:
October 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 18, 21, 22, 23, 24, 25, 26, 27, and 31, 2024
November 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 15, 19, and 20, 2024
Evening Shift:
October 2, 6, 14, and 25, 2024
November 3, 2024
Clinical record review for Residents 66 revealed a current task for staff to provide:
nursing rehab for dressing and grooming, staff to encourage resident to assist with all dressing and grooming every shift
nursing rehab eating and swallowing, staff to encourage resident to eat 50 to 75 percent of all meals.
Review of task documentation for Resident 66 revealed that staff did not document completion or documented NA of the nursing rehab grooming task on the following dates:
Day Shift:
October 27 and 31, 2024
November 1, 7, and 13, 2024
Evening Shift:
October 14, 16, 19, 25, 2024
Review of task documentation for Resident 66 revealed that staff did not document completion or documented NA of the nursing rehab eating task on the following dates:
Day Shift:
October 3, 5, 6, 7, 9, 10, 12, 13, 21, 22, 23, 25, 26, 27, and 31, 2024
November 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 15, 19, and 20, 2024
Evening Shift:
October 2, 14, and 25, 2024
November 3, 2024
Clinical record review for Residents 73 revealed a current task for staff to provide:
nursing rehab for dressing and grooming, staff to encourage resident to assist with all dressing and grooming every shift.
nursing rehab eating and swallowing, staff to encourage resident to eat 50 to 75 percent of all meals.
Review of task documentation for Resident 73 revealed that staff did not document completion or documented NA of the nursing rehab grooming task on the following dates:
Day Shift:
October 7, 13, 24, and 27 2024
November 1, and 7, 2024
Evening Shift:
October 2, 5, 6, 12, 14, 16, 19, and 25, 2024
November 3 and 17, 2024
Review of task documentation for Resident 73 revealed that staff did not document completion or documented NA of the nursing rehab eating task on the following dates:
Day Shift:
October 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 18, 21, 22, 23, 24, 25, 26, 27, and 31, 2024
November 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 15, 19, and 20, 2024
Evening Shift:
October 2, 6, 14, and 25, 2024
November 3, 2024
Clinical record review for Residents 80 revealed a current physician's order for staff to provide:
nursing rehab walking: please ambulate 125 feet daily with a rolling walker and one staff assist, cueing to take bigger steps and stand tall
nursing rehab for dressing and grooming, staff to encourage resident to assist with all dressing and grooming every shift
nursing rehab eating and swallowing, staff to encourage resident to eat 50 to 75 percent of all meals.
Review of task documentation for Resident 80 revealed that staff did not document completion or documented NA of the nursing rehab walking order on the following dates:
October 1, 2, 3, 4, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 21, 22, 25, 27, 28, 29, 30, and 31 2024
November 1, 7, 10, 11, 13, 14, 15, 18, and 19, 2024
Review of task documentation for Resident 80 revealed that staff did not document completion or documented NA of the nursing rehab grooming task on the following dates:
Day Shift:
October 3, 7, 27, and 31, 2024
November 7, 10, 14, and 15, 2024
Evening Shift:
October 2, 6, 14, 16, 25, and 30, 2024
November 3 and 16, 2024
Review of task documentation for Resident 80 revealed that staff did not document completion or documented NA of the nursing rehab eating task on the following dates:
Day Shift:
October 3, 5, 6, 7, 8, 9, 10, 12, 13, 21, 22, 23, 25, 26, 27, and 31, 2024
November 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 15, 17, 19, and 20, 2024
Evening Shift:
October 2, 6, 14, 25, and 30, 2024
November 7, 10, and 15, 2024
Clinical record review for Residents 108 revealed a current physician order for staff to provide:
a restorative nursing care walk every shift with a rolling walker one assist
nursing rehab for dressing and grooming, staff to encourage resident to assist with all dressing and grooming every shift
nursing rehab eating and swallowing, staff to encourage resident to eat 50 to 75 percent of all meals
Review of task documentation for Resident 108 revealed that staff did not document completion or documented NA of the nursing rehab walking task on the following dates:
Day Shift:
October 30 and 31, 2024
November 1, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, and 18, 2024
Evening Shift:
October 2, 5, 6, 12, 14, 16, 19, and 25, 2024
November 3, 2024
Review of task documentation for Resident 108 revealed that staff did not document completion or documented NA of the nursing rehab grooming task on the following dates:
Day Shift:
October 12 and 13, 2024
November 1, 6, 7, and 13, 2024
Evening Shift:
October 2 and 16, 2024
November 3, 2024
Review of task documentation for Resident 108 revealed that staff did not document completion or documented NA of the nursing rehab eating task on the following dates:
Day Shift:
October 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 21, 22, 23, 25, 26, and 31, 2024
November 1, 2, 3, 4, 5, 6, 7, 8, 10, 11, 12, 13, 15, 19, and 20, 2024
Evening Shift:
October 2 and 6, 2024
November 3, 2024
The surveyor reviewed the above information during an interview with the Nursing Home Administrator and the Director of Nursing on November 21, 2024, at 1:30 PM.
28 Pa. Code 211.10(c) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered treatments and medications for three...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to provide the highest practicable care regarding physician ordered treatments and medications for three of 29 residents reviewed (Residents 52, 131, and 300).
Findings include:
Clinical record review for Resident 131 revealed a diagnosis list that included sepsis (a systemic response to infection) and resistance to multiple antimicrobial drugs.
Observation of Resident 131 on November 20, 2024, at 11:00 AM revealed the resident was sitting in a wheelchair at the foot of the bed. The resident had a PICC line (peripherally inserted central catheter; a thin, soft, flexible tube inserted through a vein in the arm and passed through to the larger veins near the heart for the administration of fluids or medication) in the left arm.
Current physician orders for Resident 131 revealed an order dated November 19, 2024, that noted the resident was to receive Meropenem (an antibiotic) two grams intravenously every eight hours for sepsis related to a thigh abscess (a tender mass filled with pus caused due to infection).
Review of the November 2024 Medication Administration Record (MAR) for Resident 131 revealed that staff had not documented the resident as having received the medication as ordered, refused the medication, or was not available for administration on the following dates/times:
The 5:00 AM dose of the antibiotic on November 4, 7, 8, and 16.
The 1:00 PM dose of the antibiotic on November 14, 17, and 18.
The 9:00 PM dose of the antibiotic on November 15.
Further review of the clinical record for Resident 131 revealed an order dated November 10, 2024, that instructed staff to change the PICC line dressing every day shift every Sunday.
Review of the current care plan for Resident 131 revealed the resident has a potential for complications at the intravenous (IV) insertion site, which also included care for a dislodged PICC line (cleanse site and place a dry dressing, inspect tubing for breakage, measure the total length compared to the insertion notes and if not whole notify the physician and send the resident to the emergency room for evaluation).
The care plan for Resident 131 did not contain anything related to further assessment of possible complications related to the PICC line (such as extremity edema, infection, and/or catheter migration).
The above information was reviewed with the Nursing Home Administrator and Director of Nursing on November 22, 2024, at 1:00 PM.
Clinical record review for Resident 300 revealed the resident was ordered inner cannula (a tube that fits inside a tracheostomy) changes daily to his tracheostomy (a hole in the front of the neck into the windpipe) since October 17, 2024.
During an observation of Resident 300's tracheostomy care and inner cannula change on November 21, 2024, at 11:08 AM, Resident 300 was asked if staff were performing this task daily in which the resident responded, sometimes.
A review of Resident 300's November treatment record for the daily inner cannula changes revealed no evidence the changes were completed on November 10, 12, 16, 17 or 18, 2024. There was no evidence to indicate the resident refused or other reason the inner cannula changes were not completed or documented as completed as ordered.
An observation of Resident 300 on November 19, 2024, at 1:03 PM revealed the resident was in the dining room with a bandage over his right elbow. Resident 300 stated he had an IV there.
Clinical record review for Resident 300 revealed the resident had a fall on November 10, 2024, in which the resident sustained a skin tear to the right elbow.
Review of physician orders for Resident 300 revealed an order dated November 10, 2024, for staff to apply xeroform gauze to the right elbow daily until healed and to cleanse the area with normal saline prior to application.
An observation of Resident 300 on November 21, 2024, at 10:30 AM revealed the resident had a dressing on his right elbow. The dressing was dated November 19, 2024.
A review of Resident 300's treatment record revealed no documented evidence the resident's treatment was completed on November 20, 2024. There was no documented refusal of the treatment or reason it was not completed.
In an interview with the Nursing Home Administrator on November 21, 2024, at 11:23 AM the findings regarding Resident 300's inner cannula changes and treatment to the resident's elbow were reviewed.
Clinical record review for Resident 300 revealed the resident had recently transitioned from receiving enteral (nutritional support when a person cannot eat or drink) feedings to eating by mouth.
A nutrition progress note dated November 14, 2024, at 11:39 AM noted a family member of the resident was notified of the discontinuation of Resident 300's enteral feeding and the family member requested the resident receive a multivitamin (MVI) daily. It was noted Resident 300's physician would be contacted to order the MVI.
Review of a physician's progress note for Resident 300 dated November 15, 2024, at 5:08 PM (late entry note documented on November 17, 2024, at 11:08 AM) indicated the plan for the resident's discontinuation of the enteral feeding and order for a daily MVI was noted.
As of November 22, 2024, at 10:47 AM there was no evidence Resident 300 was ever ordered or received the daily MVI.
In a telephone interview with the Nursing Home Administrator on November 22, 2024, at 11:03 AM it was confirmed Resident 300 had no evidence the MVI was ordered or administered to the resident.
Clinical record review for Resident 52 revealed a physician's progress note dated November 12, 2024, at 3:26 PM noting a small blister on the resident's right foot had gotten larger and a new one was identified on the back of the great toe. The note indicated will have them do betadine swabs to the blisters daily to get them to shrink down.
Clinical record review for Resident 52 revealed a nursing progress note dated November 14, 2024, at 5:01 PM noting a family member of the resident was inquiring about treatment to a blister on the resident's right toe. It was noted the family member was told the resident only had an order to monitor the blister daily, and no treatment order. The family member indicated the physician confirmed a treatment order was placed. It was further noted that direct messages for a treatment order were identified, but the order had not been entered in the resident's treatment record and the treatment was added at that time on November 14, 2024.
Clinical record review for Resident 52 revealed a physician's order dated November 14, 2024, with a start date of November 15, 2024, for the resident to have betadine applied to blisters on her right dorsal foot every day and night shift.
Review of Resident 52's treatment record for November revealed once the betadine treatment was ordered there was no documented evidence the night shift treatment was completed for November 15, or 16, 2024.
In a telephone interview with the Nursing Home Administrator on November 22, 2024, at 1:00 PM the above information was reviewed regarding Resident 52.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for three of three residents reviewed...
Read full inspector narrative →
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for three of three residents reviewed (Residents 73, 122, and 300).
Findings include:
Clinical record review for Resident 73 revealed a current physician's order for staff to provide oxygen at 4 liters per minute (LPM) via NC (nasal canula, tubing to deliver oxygen to the nose), monitor (Resident 73's) oxygen saturation (the amount of oxygen in the blood) every shift and ensure the appropriate flow rate every day and evening shift.
Observation of Resident 73's oxygen concentrator on November 19, 2024, at 12:47 PM revealed that their oxygen level was set at 6 LPM. Observation on November 20, 2024, at 10:52 AM revealed that Resident 73's oxygen level set was at 6.5 LPM. On November 21, 2024, at 2:26 PM revealed Resident 73's oxygen level was set at 6.5 LPM. Concurrent interview with Employee 2, nurse aide, confirmed the observation. During each observation, Resident 73's oxygen concentrator was located at the head of their bed and out of their reach. Resident 73 was unable to change the oxygen level independently.
Review of Resident 73's oxygen monitoring documentation for October and November 2024, revealed there was no documentation that staff monitored Resident 73's oxygen level on the following dates:
October 6, 7, 24, 25, and 31, 2024, day shift
October 5, 2024, evening shift
November 6, 18, and 19, 2024, day shift
There was documentation that staff monitored Resident 73's oxygen level on November 20 and 21, 2024, day shift, however this surveyor observed Resident 73's oxygen administration level above the physician's ordered level both days.
The surveyor reviewed the above information for Resident 73 during observation and interview with the Director of Nursing and the Nursing Home Administrator on November 21, 2024, at 2:39 PM.
Observations on the Second Floor [NAME] Nursing Unit on November 19, 2024, at 9:32 AM and 10:53 AM revealed a wheelchair in the main resident hallway with a nasal cannula attached to a portable oxygen cylinder. The nasal cannula was unprotected from contamination and draped over the back of the wheelchair and coiled on the seat. The nasal cannula was not labeled or dated. The wheelchair did not have a resident name tag on it.
An interview with Employee 1, licensed practical nurse, on November 19, 2024, at 10:57 AM revealed it was unclear who the nasal cannula belonged to and she unsure how the nasal cannula should be stored and protected from contamination.
An interview with Employee 6, nurse aide, on November 19, 2024, at 11:05 AM revealed that the wheelchair and nasal cannula belonged to Resident 122. Employee 6 proceeded to remove the nasal cannula.
The above information for Resident 122 was reviewed with the Nursing Home Administrator and Director of Nursing on November 20, 2024, at 2:47 PM.
Observation of Resident 300's room on November 19, 2024, 12:30 PM revealed the resident was out of the room and the bed was made. A large plastic cart labeled tracheostomy cart was observed beside the resident's bed. A nebulizer with an attached mask was lying on top of the cart. The mask was not covered. A suction machine was observed next to the nebulizer. The end of the suction tubing was lying on top of the cart uncovered.
A follow up observation of Resident 300's room on November 20, 2024, at 10:03 AM revealed the resident was out of the room. The suction tubing end and nebulizer mask remained lying on top of the cart uncovered. An oxygen concentrator beside the bed was also observed with nasal mask on the end of the oxygen tubing, which was uncovered pinned between the concentrator and the tracheostomy cart.
The above findings regarding the storage of Resident 300's respiratory equipment were reviewed with the Nursing Home Administrator and Director of Nursing on November 20, 2024, at 2:45 PM.
483.25(i) Respiratory/tracheostomy Care and Suctioning
Previously cited 12/8/23
28 Pa. Code 211.10 (c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected multiple residents
Based on observation, clinical record review, review of select manufacturer's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five p...
Read full inspector narrative →
Based on observation, clinical record review, review of select manufacturer's guidelines, and staff interview, it was determined that the facility failed to ensure a medication error rate below five percent (Residents 1 and 94).
Findings include:
The facility's medication error rate was 16 percent based on 25 medication opportunities with four medication errors.
Observation of a medication administration pass on November 19, 2024, at 9:30 AM revealed Employee 1, licensed practical nurse (LPN), preparing to administer Insulin Lispro (helps regulate blood sugars) 60 units, Dulera (used to control symptoms of asthma) inhaler, and Flonase (used to help with nasal allergies) nasal spray to Resident 1.
Review of Resident 1's clinical record revealed a physician's order dated October 22, 2024, that indicated nursing staff are to administer the Insulin Lispro before meals. Employee 1 administered the Insulin Lispro almost 90 minutes after Resident 1 ate her breakfast.
Review of the manufacturer's guidelines for the use of Dulera revealed that once the administration is complete, the user is to rinse their mouth out with water and spit the water out. Employee 1 handed the Dulera inhaler to Resident 1. Resident 1 administered two sprays and did not rinse her mouth out after administration. Employee 1 also did not provide any instructions to Resident 1 regarding rinsing her mouth after use.
Review of the manufacturer's guidelines for the use of Flonase revealed that the user should blow their nose prior to use and to also hold closed the opposite nostril when administering. Employee 1 handed the Flonase to Resident 1. Resident 1 administered one spray to each of her nostrils. Resident 1 did not blow her nose and did not hold the opposite nostril closed. Employee 1 did not provide instructions to Resident 1 regarding blowing her nose prior to use or holding the opposite nostril closed while administering.
Interview with Employee 1 on November 19, 2024, at 1:30 PM confirmed the above observations.
Observation of a medication administration pass on November 20, 2024, at 9:02 AM with Employee 7, LPN, revealed she administered Glipizide (a medication used to help regulate blood sugar) 5 milligrams to Resident 94. The medication label indicated that Glipizide was to be given before meals. Employee 7 administered Glipizide after Resident 94 already ate her breakfast.
Interview with Employee 7 on November 20, 2024, at 2:30 PM confirmed that she administered Resident 94's Glipizide after she already ate breakfast.
The Nursing Home Administrator and Director of Nursing were made aware of the concerns with medication administration during a meeting on November 21, 2024, at 2:22 PM.
483.45(f) Medication Errors
Previously cited 12/8/23
28 Pa. Code 211.10(a) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0809
(Tag F0809)
Could have caused harm · This affected multiple residents
Based on review of the facility meal schedule, observation, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times i...
Read full inspector narrative →
Based on review of the facility meal schedule, observation, and resident and staff interview, it was determined that the facility failed to ensure that meals were served at regularly scheduled times in accordance with resident needs on three of five nursing units (Resident 9 and 108; Second Floor East, Second Floor West, and Third Floor East)
Findings include:
Review of the facility's resident food committee minutes dated October 17, 2024, revealed the residents indicated dinner is late.
Observation on the Second-Floor East nursing unit on November 19, 2024, at 12:28 PM revealed staff passing lunch meal trays on the unit. Several trays remained in the cart waiting to be passed. Resident 9 who resides on the unit was observed being served lunch during an interview with the resident at 12:40 PM. Resident 9 indicated meals are often late and never when they are told they are going to be, stating she was supposed to get her lunch around noon. Resident 9 requested an alternate entrée at the time the meal tray was served to her. The alternate entrée was observed being served to the Resident 9 at 1:01 PM.
Observation of the lunch tray line in the facility's main kitchen on November 21, 2024, at 12:17 PM revealed multiple dietary staff assembling resident meal trays. Staff were observed to have completed the first cart for delivery to the Second [NAME] nursing unit and the cart left the kitchen at 12:39 PM. Observation on the Second-Floor [NAME] nursing unit revealed the cart arrived on the unit at 12:43 PM when staff immediately started passing the trays. The last tray was served off the cart at 1:23 PM.
A review of the facility mealtimes document revealed the lunch meal is to be served to residents on the Second-Floor East unit from 12:05 - 12:10 PM depending if the tray is on first or second cart for the unit. Resident 9 was served at 12:40 PM on November 19, 2024, a half hour after the approximate delivery time for her lunch. The approximate time for lunch service on the Second Floor [NAME] first cart noted as observed above, was 12:20 PM. The cart did not leave the kitchen until 12:39 PM and the last tray was not served off the cart until 1:23 PM over one hour past the approximate meal service time.
The above findings were reviewed with the Nursing Home Administrator and Director of Nursing on November 21, 2024, at 1:30 PM.
Review of the posted mealtimes for the Third Floor East Nursing Unit revealed that the lunch food trays are scheduled to arrive on the unit at 12:45 PM.
Observation of the Third Floor East Nursing Unit on November 21, 2024, at 1:20 PM revealed multiple residents in the dining room awaiting lunch trays, which had not arrived to the unit. Three staff members were also observed at the nurse's station awaiting lunch trays to arrive.
Observation of the Third Floor East Nursing Unit on November 21, 2024, at 1:26 PM revealed that the lunch food trays arrived on the unit (over 45 minutes late per the posted mealtimes) via the food tray cart and staff began passing the meal trays.
Interview with Resident 108 on November 19, 2024, at 10:41 AM revealed that she waits almost an hour (7:00 PM) for her supper meal tray to arrive.
The above information for the Third Floor East Nursing Unit was reviewed with the Nursing Home Administrator on November 22, 2024, at 1:00 PM.
28 Pa. Code 201.14(a) Responsibility of licensee
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
Based on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for four of five residen...
Read full inspector narrative →
Based on clinical record review, facility documentation, and staff interview, it was determined that the facility failed to ensure complete and accurate clinical documentation for four of five residents reviewed for restorative nursing services (Residents 47, 66, 80, and 108).
Findings include:
Review of the facility's meal service times revealed that the breakfast meal tray carts for the 2W Nursing Unit were to be delivered to the unit at 7:50 AM and 8:00 AM respectively.
Clinical record review for the following residents revealed that staff documented that they provided nursing rehab for eating and swallowing and encouraging residents to eat 50-75 percent of the meal prior to the facility delivering their breakfast tray.
Review of Resident 47's October and November 2024 Task documentation (a document staff use to indicate the Resident's self-performance and staff support needed while completing a task and/or receiving care) revealed staff documentation prior to 7:50 AM that they provided nursing rehab for eating and swallowing on:
October 1, 28, and 30, 2024
November 13, 14, 16, and 18, 2024
Review of Resident 66's October and November 2024 Task documentation revealed staff documentation prior to 7:50 AM that they provided nursing rehab for eating and swallowing on:
October 1 and 30, 2024
November 13, 14, 16, and 18, 2024
Review of Resident 80's October and November 2024 Task documentation revealed staff documentation prior to 7:50 AM that they provided nursing rehab for eating and swallowing on:
October 1, 4, 29, and 30, 2024
November 2, 13, 14, 16, and 18, 2024
Review of Resident 108's October and November 2024 Task documentation revealed staff documentation prior to 7:50 AM that they provided nursing rehab for eating and swallowing on:
October 1, 2, 17, 18, 29, and 30, 2024
November 13, 14, and 16, 2024
This surveyor reviewed the above information during an interview on November 22, 2024, at 1:30 PM with the Nursing Home Administrator and the Director of Nursing.
28 Pa. Code 211.5 (f) Medical records
28 Pa. Code 211.12(d)(1)(5) Nursing Services
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food ...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food contamination in the facility's main kitchen and on two of five nursing units (Second Floor East, Third Floor West)
Findings include:
Observation of the facility's main kitchen on November 19, 2024, at 11:00 AM revealed the following:
Handwashing sinks located inside the kitchen entrance, beside the three-compartment sink area, snack preparation are, and dishwashing area were observed with brown staining, and with dust, dirt, and debris buildup on the surrounding faucet area.
Small tan colored trashcans located beside the above noted handwashing sinks were observed with dried liquid spills and buildup of dust/dirt on the exteriors. The wall area behind the trash receptacle by the handwashing sink in the three-compartment sink area was observed with multiple areas of dried liquid/food splatter.
The frame of the linen cart stored beside the handwashing sink upon entrance to the kitchen was dusty and dirty.
Large gray trash bins located throughout the kitchen were observed with dust, food crumbs, and dried liquid spills on the lids and exterior of the containers.
Flooring throughout the cooking area containing, the fryer, stove top, ovens, and steamers was observed with debris and dirt buildup under the equipment and along wall edges. The conduit, wires and pipes behind the oven, stove, and fryer were covered in thick dust.
Significant dirt and debris were observed on the flooring extending from the three-compartment sink area, under the pot/pan shelving unit, and into the bakery room. The pot and pan shelving unit frame appeared corroded with pieces chipping off the unit onto the floor. The shelves contained dust and debris.
Large floor drains, which extended on the floor in front of three steamers, steam kettle and tilt skillet were observed with significant food debris buildup down in the drain. The metal grates, which covered the drain trough area were observed with significant dried food/debris buildup hanging from the holes in the metal grate covers. The covers were observed screwed in place. Employee 3, dietary manager, indicated maintenance would need contacted to unscrew the grates so the area could be cleaned.
The lower portion of the steam kettle was observed covered with dried food splatter.
The frame of the tilt skillet was observed dusty and sticky.
A floor drain under the sink across from the tilt skillet was observed with dried food and debris.
The interior base of a portable two door cooler across from the tilt skillet was observed with dust, and debris build up.
A white plastic bowl was found inside the microwave covered with a piece of plastic wrap labeled butter 11/13 11/14. The butter appeared to have been melted and rehardened to the shape of the container.
A floor drain under the coffee station area contained a dried pepper pack and debris.
The flooring under the ice machine contained significant dirt and debris extending to the area behind the machine. The drain under the ice machine contained debris and was covered significantly in a white substance.
A dish rack full of clear two handled plastic cups was observed in the snack preparation area. Employee 3 indicated the cups were clean. Many of the cups were significantly stained brown.
The interior of the snack preparation area's portable cooler contained dried food and debris.
Observation of the nourishment room located on the Second-Floor East nursing unit on November 20, 2024, at 10:56 AM revealed brown stains in the sink, and a large amount of white buildup on the faucet area. The countertop was covered in crumbs, brown and black stains, and dried liquid ring spots. The interior of the microwave was covered in dried food, and brown discoloration of the white interior. A lower cabinet containing a box of plasticware, and a plastic sleeve of cup lids contained dust and debris in the interior base and interior frame of the door and dried liquid spills.
A cabinet under the sink, which was labeled with a sign stating, Do not store anything in the cupboard, was observed with an empty soda can sitting in the corner of the cabinet. The interior base of the cabinet had several dried liquid spots under the sink pipes.
The interior of a refrigerator/freezer in the room was observed with a frozen red substance in the interior base of the freezer and the interior of the refrigerator door was observed dirty with black and brown areas. The interior base of the refrigerator was observed with debris buildup. A drawer in the refrigerator contained several containers of Nutren nutritional supplement, and was observed with a dried red sticky substance, dirt, dust, and a straw with the wrapper covered in the red substance dried and stuck the base of the drawer.
A Nursing unit kitchen check sheet was observed on the door inside the nourishment room, which was last dated 11/19/24, with checked off marks for 7 PM - 7AM, indicating the microwave, counters, refrigerator, freezer were all clean.
An observation of the Third-Floor [NAME] nourishment room on November 20, 2024, at 11:16 AM revealed the exterior metal vents of the microwave were blackened and discolored. The interior of the microwave contained multiple black spots and dried food debris.
A cabinet under the sink was observed with black spots on the interior wood and black debris. An additional lower cabinet where plasticware and foam cups were stored was observed with dried brown spills and debris buildup on the interior of the door frame extending into the interior base of the cabinet.
The interior of the refrigerator contained dried spills and debris. The interior of the freezer had a black/brown substance throughout.
A nursing unit kitchen check sheet, was observed in the Third-Floor [NAME] nourishment room and was checked off for November 20, 2024, 7 AM - 7 PM that the microwave and refrigerator were clean.
The above findings were reviewed with the Nursing Home Administrator on November 21, 2024, at 1:30 PM.
28 Pa. Code 201.14 (a) Responsibility of licensee
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
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on observation, and staff interview, it was determined that the facility failed to ensure resident's privacy on one of five nursing units (2 [NAME] Nursing Unit).
Findings include:
Observation o...
Read full inspector narrative →
Based on observation, and staff interview, it was determined that the facility failed to ensure resident's privacy on one of five nursing units (2 [NAME] Nursing Unit).
Findings include:
Observation of the 2 [NAME] nursing unit on October 31, 2024, revealed the following:
At 12:21 PM, Employee 1 returned to the medication cart, poured resident medications, and left again to go down the hallway. Employee 1 left a resident clinical record open and in full view/access to anyone choosing to access said record. At this time, one non-licensed staff member was in the vicinity of the medication cart and several residents were congregated near the medication cart and nurse's station.
At 12:22 PM, Employee 1 returned to the medication cart, poured resident medications, and immediately left the vicinity of the medication cart. Employee 1 again left a resident's clinical record open and in full view/access to anyone.
At 12:24 PM, Employee 1 returned to the medication cart and poured resident medications.
At 12:37 PM, Employee 1 left the medication cart, walked to a resident sitting near the nurse's station, but out of sight of the medication cart. Employee 1 again left a resident's clinical record open and in full view/access to anyone. Employee 1 administered the resident's medication, returned to the medication cart, and poured more medications.
At 12:38 PM, Employee 1 left the medication cart. Employee 1 again left a resident's clinical record open and in full view/access to anyone. Non-licensed staff were at the nurse's station at the time of the observation.
At 12:44 PM, while Employee 1 was away from the medication cart in a resident's room the Nursing Home Administrator (NHA) approached the nurse's station and medication cart. The NHA observed and acknowledged that at resident's clinical record was open, in full view/access to anyone without any licensed staff in the vicinity. There were several residents and staff were nearby and had access/could potentially access the resident's clinical record. The NHA located Employee 1 in a resident's room and informed them that the resident's clinical was in full view while they were not in the vicinity of the cart.
At 12:45 PM, Employee 1 returned to the medication cart.
Interview and concurrent observation on October 31, 2024, at 12:44 PM, with the Nursing Home Administrator and confirmed the above findings.
28 Pa. Code 201.29 (c.3)(4) Resident rights
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, it was determined that the facility failed to ensure appropriate medication security on one of five nursing units (2 [NAME] nursing unit).
Findings include:
O...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to ensure appropriate medication security on one of five nursing units (2 [NAME] nursing unit).
Findings include:
Observation of the 2 [NAME] nursing unit on October 31, 2024, revealed the following:
At 11:12 AM upon arrival to the 2 [NAME] nursing unit the surveyor observed the unit's medication cart was unlocked while it was near the nurse's station. No licensed staff were observed in the vicinity. There were several residents congregated near the nurse's station.
At 11:13 AM Employee 1, licensed practical nurse, returned to the medication cart from down the hallway and out of view of the medication cart.
At 12:02 PM the surveyor observed the unit's medication cart unlocked in the same location as above. No licensed staff were observed in the vicinity. There were several residents congregated near the nurse's station.
At 12:04 PM Employee 1 returned to the medication cart from down the hallway and out of view of the medication cart, removed medications, and left the vicinity of the medication cart.
At 12:11 PM Employee 1 returned to the medication cart, identified a residents call bell was ringing across from the nurse's station, immediately responded to the call bell, went to the nursing unit's kitchen area, then returned to the medication cart.
At 12:13 PM Employee 1 poured resident medications and went down the hallway out of sight of the medication cart.
At 12:16 PM Employee 1 returned to the medication cart.
At 12:19 PM Employee 1 poured resident medications and went down the hallway out of sight of the medication cart. At this time four non-licensed staff were in in the vicinity of the medication cart.
At 12:21 PM Employee 1 returned to the medication cart, poured resident medications, and left again to go down the hallway out of sight of the medication cart. At this time, one non-licensed staff member was in the vicinity of the medication cart.
At 12:22 PM Employee 1 returned to the medication cart, poured resident medications, and immediately left the vicinity of the medication cart.
At 12:24 PM Employee 1 returned to the medication cart and poured resident medications.
At 12:37 PM Employee 1 left the medication cart, walked to a resident sitting near the nurse's station, but out of sight of the medication cart, administered their medication, returned to the medication cart, and poured more medications.
At 12:38 PM Employee 1 left the medication cart. Non-licensed staff were at the nurse's station at the time of the observation.
At 12:44 PM while Employee 1 was away from the medication cart in a resident's room the Nursing Home Administrator (NHA) approached the nurse's station and medication cart. The NHA observed and acknowledged that the 2 [NAME] nursing unit's medication cart was unlocked without any licensed staff in the vicinity while several residents and staff were nearby and had access to medications. The NHA located Employee 1 in a residents room and informed them that the medication cart was unlocked when they were not in the vicinity of the cart.
At 12:45 PM Employee 1 returned to the medication cart and locked the cart.
From 12:02 PM to 12:45 PM (43 minutes) Employee 1 left the 2 [NAME] nursing unit's medication cart unlocked while they poured and passed medications to residents located away from the medication cart. Employee 1 did not have direct visualization of the medication cart for 23 minutes of this observation.
28 Pa. Code 211.9(k) Pharmacy services
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
Jun 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
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident, family, and staff interview, it was determined that the facility failed to assist ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident, family, and staff interview, it was determined that the facility failed to assist dependent residents with bathing, repositioning, and toileting care for two of seven residents reviewed (Residents 2 and 7).
Findings include:
Interview with Resident 2 and her husband on June 3, 2024, at 12:15 PM revealed that staff do not provide care every two hours as she is supposed to have. Resident 2 stated that she has discomfort sitting in the same position for long periods of time.
Clinical record review of a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated May 5, 2024, revealed that staff assessed Resident 2 as needing the extensive assistance of two staff for bed mobility, and that she was dependent on the assistance of two staff for transfers.
An active physician's order dated November 30, 2023, instructed staff to turn and reposition Resident 2 every two hours.
A plan of care developed by the facility to address Resident 2's bowel incontinence related to immobility listed interventions that included instructions for staff to check and change Resident 2 every two hours and as needed since December 16, 2023.
Review of Task documentation (electronic system of nurse aide documentation of activities of daily living care) dated May 2024, and June 2024, revealed that staff failed to assist Resident 2 with her bowel incontinence program every two hours for the following shifts:
Day shift
May 19, 2024
Night shift
May 6, 14, 25, and 28, 2024
June 1, 2024
Task documentation dated May 2024 and June 2024 revealed that staff failed to assist Resident 2 with her check and change program every two hours for the following shifts:
Day shift
May 19 and 21, 2024
Night shift
May 4, 8, 13, 16, 22, 25, 29, and 31, 2024
June 1, 2024
The surveyor reviewed the above concerns regarding Resident 2's elimination and repositioning care during an interview with the Nursing Home Administrator and the Director of Nursing on June 3, 2024, at 2:45 PM.
Interview with Resident 7 on June 3, 2024, at 12:53 PM revealed that he received a shower approximately every other week.
Clinical record review for Resident 7 revealed a quarterly MDS dated [DATE], that assessed him as needing setup and clean up assistance with bathing.
Task documentation for Resident 7 confirmed that staff did not document any assistance with bathing for the 11 days between May 5 and 16, 2024, and for the 10 days between May 20 and 30, 2024.
The surveyor reviewed the above concerns regarding Resident 7's assistance with bathing during an interview with the Nursing Home Administrator and the Director of Nursing on June 3, 2024, at 2:45 PM.
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 F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide services to maintain a resident's mobility for one of seven residents reviewed (...
Read full inspector narrative →
Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide services to maintain a resident's mobility for one of seven residents reviewed (Resident 6).
Findings include:
Interview with Resident 6 on June 3, 2024, at 12:50 PM revealed that staff have not walked with her per her walking program. Resident 6 stated that she believed that there were not enough staff to walk with her, and the facility restructured their nurse aide staffing to no longer have dedicated restorative nursing aides.
Clinical record review for Resident 6 revealed a plan of care developed by the facility to address her deficit with self-care of activities of daily living (ADL) performance. Interventions for the plan of care included a nursing rehabilitation program to ambulate 200-250 feet twice with one staff assist, a roller walker, and a wheelchair following (as resident may get dizzy).
Review of Task documentation (electronic system of nurse aide documentation of activities of daily living care) dated May 2024, and June 2024, revealed that staff failed to assist Resident 6 with her restorative ambulation program on May 2, 3, 4, 5, 6, 7, 10, 11, 16, 18, 20, 25, 26, 29, 30, 31, 2024, and June 2, 2024.
The surveyor reviewed the above concerns regarding Resident 6's restorative nursing program during an interview with the Nursing Home Administrator and the Director of Nursing on June 3, 2024, at 2:45 PM.
483.25(c)(1)-(3) Increase/prevent Decrease In ROM/mobility
Previously cited deficiency 12/8/23
28 Pa. Code 211.12(d)(1)(5) Nursing services
Dec 2023
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to establish clear and consistent resident's wishes regarding...
Read full inspector narrative →
Based on clinical record review, review of select policies and procedures, and staff interview, it was determined that the facility failed to establish clear and consistent resident's wishes regarding advance directives (written instruction, such as a living will or durable power of attorney, relating to the provision of healthcare, for a time when a resident may be incapacitated and not able to make decisions) for one of two residents reviewed (Resident 66).
Findings include:
The policy entitled POLST, last reviewed on September 20, 2023, indicates that if a resident or their responsible party is not ready to complete a POLST (Pennsylvania Orders for Life Sustaining Treatment, a form that allows people with serious or chronic illnesses or the frailties of age to spell out what kinds of medical care they would want in potential future emergencies), nursing staff are to inform the resident and/or the RP (responsible party) that until a decision is made, the resident will be considered a full code.
Review of Resident 66's clinical record revealed that the facility admitted him on September 26, 2023. Nursing documentation dated September 29, 2023, indicated that the facility sent out a POLST form to be filled out by Resident 66's potential guardians' daughter.
There was no documented evidence in Resident 66's clinical record to indicate that the POLST was returned, or that the facility initiated a code status upon Resident 66's admission. The facility continued to not have a physician's order for code status until the surveyor brought up the concerns on December 6, 2023, two months after her initial admission.
Interview with the Administrator and Director of Nursing on December 7, 2023, at 1:49 PM confirmed the above findings for Resident 66.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 201.29(a) Resident rights
28 Pa. Code 211.5(f) Clinical Records
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, employee personnel records, and staff interview, it was determined that the facility fai...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, employee personnel records, and staff interview, it was determined that the facility failed to develop and implement an abuse prohibition policy that required a thorough investigation of prospective employee's employment history for three of five newly hired employees reviewed (Employees 3, 4, and 5).
Findings include:
The policy entitled Resident Abuse and Neglect Prevention Program last reviewed without changes on September 20, 2023, revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation as defined by the regulation. The facility will develop and implement written policies and procedures to prohibit and prevent abuse including screening of new/potential staff. The facility will conduct a criminal background investigation on all prospective staff utilizing the (Pennsylvania) state police (PSP) and the FBI (federal bureau of investigation) if the potential candidate has not resided in the state of Pennsylvania for the past two years. Results of the criminal background investigation shall be available within 30 days of hir for state police reports and within 90 days for FBI reports. New staff will not be permitted to continue working if the report results are not received within the appropriate time frame. Return to duty shall be dependent upon receipt of an acceptable background investigation.
Review of Employee 3's, dietary manager, personnel record revealed that the facility hired them on August 7, 2023. Employee 3's personnel record did not reveal any evidence that the facility attempted to obtain or complete a PSP background check to determine criminal history for Employee 3.
Review of Employee 4's, licensed practical nurse, personnel record revealed that the facility hired them on September 15, 2023. Employee 4's personnel record did not reveal any evidence that the facility attempted to obtain or complete a PSP background check to determine criminal history for Employee 4
Review of Employee 5's, [NAME], personnel record revealed that the facility hired her on November 16, 2023. Employee 5's personnel record revealed that she indicated that she lived in Pennsylvania within the past two years; however, Employee 5's employee history revealed that she did not live within Pennsylvania for two years. Review of Employee 5's personnel record did not reveal any evidence that the facility initiated and/or completed fingerprinting or an FBI background check to ensure residency and criminal history prior to identification by the surveyor.
This surveyor reviewed this information during an interview with Employee 6, human resources, and the Nursing Home Administrator on December 8, 2023, at 11:20 AM.
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 201.19 Personnel policies and procedures
28 Pa. Code 201.29(a) Resident rights
28 Pa. Code 211.12(d)(1)(5) Nursing services
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 clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility's bed hol...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident or resident representative received written notice of the facility's bed hold policy at the time of transfer for three of 10 residents reviewed for hospitalizations (Residents 25, 74, and 106).
Findings include:
Clinical record review for Resident 74 revealed that he was transferred to the hospital on November 3, 2023, for respiratory distress. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out of the facility.
Interview with the Nursing Home Administrator on December 8, 2023, at 9:45 AM confirmed that the facility did not provide a written bed hold notice to Resident 74 or his responsible party.
Clinical record review for Resident 25 revealed that they were transferred to the hospital on November 2, 2023, after they had a change in condition. There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out to the hospital.
Clinical record review for Resident 106 revealed that they were transferred to the hospital on November 3, 10, and 14, 2023, after there was a change in their condition.
There was no documentation available that the facility provided written notice regarding a bed hold to the resident and/or the resident's responsible party upon transfer out to the hospital.
The surveyor reviewed the above information during an interview with the Nursing Home Administrator on December 8, 2023, at 9:45 AM.
The facility failed to provide written notice of their bed hold policy at the time of transfer for Residents 25, 74, and 106.
28 Pa. Code 201.14(a) Responsibility of licensee
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 clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two of 25 residents reviewed (Residents 51 and 113).
Findings include:
Review of Resident 51's clinical record revealed a Minimum Data Set Assessment (MDS, a form completed at specific intervals to determine care needs) dated October 23, 2023, that indicated the facility assessed him as having a psychotic disorder. There was no documented evidence in Resident 51's clinical record to support a diagnosis of psychotic disorder.
Review of Resident 113's clinical record revealed an MDS dated [DATE], and September 26, 2023, that indicated the facility assessed him as having a psychotic disorder. There was no documented evidence in Resident 113's clinical record to support a diagnosis of psychotic disorder.
Interview with Employee 2, MDS assessment coordinator, on December 8, 2023, at 9:47 AM, confirmed the above findings for Resident 51 and Resident 113 and the assessments were not accurate.
483.20(g) Accuracy of Assessments
Previously cited 1/27/23
28 Pa. Code 211.5(f)(ix) Medical records
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and family interview, it was determined that the facility failed medically justify and...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and family interview, it was determined that the facility failed medically justify and evaluate the clinical necessity for a urinary catheter for one of two residents reviewed (Resident 43).
Findings included:
Clinical record review for Resident 43 revealed the facility admitted him on July 22, 2022. Resident 43 was admitted to the hospital from [DATE] to 17, 2023, for evaluation and treatment of his left second toe.
An interview with Resident 43's family on December 5, 2023, at 2:06 PM revealed that Resident 43 had a catheter put in at the hospital. She stated that he did not have a urinary catheter (insertion of a tube into the bladder to remove urine) prior to Resident 43's hospitalization on November 13, 2023.
A review of Resident 43's physician orders revealed a new order dated November 23, 2023, for staff to insert a Foley catheter16 French with a 5 milliliter (mL) balloon.
A review of Resident 43's clinical record revealed no medical justification for the continued use of Resident 43's catheter.
An interview with the Director of Nursing on December 8, 2023, at 11:08 AM confirmed these findings. The Director of Nursing stated that Resident 43 was re-admitted from the hospital on November 17, 2023, with a catheter, but the facility did not obtain a physician's order for the catheter at that time.
28 Pa. Code: 211.12 (c)(d)(1)(3)(5) Nursing Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of five residents reviewed (R...
Read full inspector narrative →
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to provide appropriate respiratory care and services for one of five residents reviewed (Resident 21).
Findings include:
According to the American Association for Respiratory Care proper cleansing of respiratory (nebulizer) equipment reduces infection risk. The longer a dirty nebulizer sits and is allowed to dry, the harder it is to clean thoroughly. Parts of the aerosol drug delivery device should be rinsed and then washed with soap and hot water after each treatment. Once completely dry, store the nebulizer cup and mouthpiece in a zip lock bag.
Clinical record review for Resident 21 revealed a current physician's order for staff to administer a CPAP (continuous positive airway pressure, a device to help treat sleep apnea) device at bedtime.
Observation of Resident 21 revealed that there was a CPAP mask unbagged and lying on a shelf beside her bed or on the floor on the following dates and times:
December 5, 2023, at 10:27 AM, on shelf by bed
December 6, 2023, at 12:04 PM and December 7, 2023, at 12:35 PM, on the floor
The surveyor reviewed the above information for Resident 21 during an interview with the Director of Nursing and the Nursing Home Administrator on December 7, 2023, at 1:30 PM.
28 Pa. Code 211.10 (c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing Services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding coordination of dialysis services and adm...
Read full inspector narrative →
Based on clinical record review and resident and staff interview, it was determined that the facility failed to provide the highest practicable care regarding coordination of dialysis services and administration of physician ordered medications for one of one resident reviewed (Resident 14).
Findings include:
Clinical record review for Resident 14 revealed that she received kidney dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly) on Mondays, Wednesdays, and Fridays at an outside provider.
Further clinical record review revealed that her plan of care indicated the facility could administer her morning medications prior to leaving for dialysis on Mondays, Wednesdays, and Fridays.
Interview with Resident 14 on December 6, 2023, at 11:41 AM indicated that she leaves for dialysis on Mondays, Wednesdays, and Fridays at 4:10 AM. She indicated that she eats her breakfast and takes her morning medications prior to going to dialysis.
Resident 14 currently receives the following medications at 4:00 AM prior to leaving the facility on her dialysis days: Eliquis (a blood thinner) 2.5 mg (milligram), Levothyroxine (treats low thyroid activity) 100 micrograms, Allopurinol (used to treat gout) 100 mg, omeprazole (used to treat certain conditions where there is too much acid in the stomach) 40 mg, Renvela (used to lower the phosphorus in the blood in dialysis patients) 800 mg, and Tylenol (a mild pain reliever and fever reducer) 325 mg 2 tabs.
Interview with the Director of Nursing on December 8, 2023, at 10:52 AM revealed that the facility does not have a process to determine if the above ordered medications should be given before or after dialysis.
The facility failed to provide the highest practicable care regarding coordination of dialysis services and administration of physician ordered medications for Resident 14.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on clinical record review, select facility policies, and staff and resident interview, it was determined that the facility failed to obtain physician ordered medications for one of 25 residents ...
Read full inspector narrative →
Based on clinical record review, select facility policies, and staff and resident interview, it was determined that the facility failed to obtain physician ordered medications for one of 25 residents reviewed (Resident 25).
Findings include:
The current facility policy entitled Medication Availability Policy, last reviewed without changes on September 20, 2023, revealed that when a medication was unavailable the LPN (licensed practical nurse) or RN (registered nurse) must check for overstock in the medication room, check central supply for possible availability, and call the supervisor and make them aware of the unavailable medication with the RN checking the emergency box/pyxsis (a medication dispensing system). If the medication was still unavailable, the RN will contact the pharmacy to send on the next run. If the medication was emergent, call the physician to obtain prescription from the backup pharmacy and notify the physician that the dose will be administered as soon as it was delivered and if ok per the physician. The RN will notify the LPN/RN on the cart, with documentation of the physician notification.
Clinical record review for Resident 25 revealed physician orders dated June 9, 2023, for the following:
Lorazepam Tablet 0.5 milligram (mg) one tablet by mouth (PO) two times a day (BID) for Anxiety
Loratadine Tablet 10 mg one tablet PO daily for allergy symptoms
Vitamin D3 Tablet 5000 units one tablet PO daily for supplement
Ibuprofen Oral Tablet 400 mg one tablet PO BID for pain management
Topiramate Tablet 50 MG Give 1 tablet by mouth two times a day for Migraines
Risperdal Consta Suspension Reconstituted 37.5 mg intramuscularly (in the muscle) every 14 days for Bipolar Disorder
Review of Resident 25's October and November 2023 MAR (medication administration record, a form to document medication administration) revealed that staff documented other/see nurses notes on October 31, 2023, for Lorazepam (two doses), Ibuprofen (two doses), Topiramate (two doses), Vitamin D3 (one dose), and Loratadine (one dose), on November 1, 2023, for Lorazepam (one dose), and on November 24, 2023, for her Risperdal injection.
Review of Resident 25's nurse's notes dated October 31, 2023, at 10:01 AM revealed that her Lorazepam, Vitamin D3, Topiramate, and Ibuprofen medications were unavailable, not in E-kit. DON (Director of Nursing) made aware. On November 1, 2023, at 7:38 AM staff indicated that for Resident 25's Lorazepam that there was none in the facility. On November 24, 2023, at 6:31 PM staff indicated that Resident 25's Risperdal medication (was) not present, RN supervisor made aware.
Review of Resident 25's clinical record revealed that staff administered her Risperdal on November 10, 2023. There was no administration on November 24, 2023, (14 days thereafter) and until identified by the surveyor.
There was no documentation in Resident 25's clinical record that indicated facility staff contacted the physician and/or the pharmacy to receive an emergency delivery or make arrangements via a third-party pharmacy regarding obtaining her medications.
Interview with Resident 25 on December 5, 2023, at 10:17 AM confirmed that she missed the above noted medications at the end of October/beginning of November. She revealed that she has a Bipolar diagnosis and by missing her Lorazepam doses, she believed that it caused her to experience a panic attack with her shoulder and arm going numb and needed transport to the emergency room.
The above information was reviewed during an interview with the Director of Nursing on December 7, 2023, at 11:19 AM.
28 Pa. Code 211.9 (k) Pharmacy services
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate less than five percent (Resident 58).
Findings include:
...
Read full inspector narrative →
Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure a medication error rate less than five percent (Resident 58).
Findings include:
The facility's medication error rate was 8 percent based on 25 medication opportunities with two medication errors.
Clinical record review for Resident 58 revealed current physician's orders for the nurse to administer the following medications:
Lacosamide 150 milligram (mg) tablet one every 12 hours for seizures (a burst of uncontrolled electrical activity in the brain that causes temporary abnormal muscle tone or movements).
Finasteride 5 mg tablet one time a day for urinary retention (difficulty urinating). The medication administration record indicated do not crush or split the tablet. Should not be handled by women of child-bearing age. Women who are pregnant or may get pregnant must not handle broken or crushed tablets.
Observation of the medication administration pass for Resident 58 on December 7, 2023, at 9:45 AM revealed that Employee 7, licensed practical nurse, crushed the lacosamide and finasteride tablets and administered them in pudding to the resident. Immediately after preparing the medications for Resident 58, Employee 7 confirmed with the surveyor the medication she crushed and capsules she opened to administer to the resident.
During an interview with Employee 8, pharmacist, on December 7, 2023, at 11:20 AM it was confirmed that lacosamide should not be crushed as it is a medication provided for seizures and that finasteride should not be crushed and it is written in the order not to crush it.
The surveyor reviewed the above findings for Resident 58 during an interview with the Nursing Home Administrator on December 7, 2023, at 11:30 AM.
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies and procedures, and staff interview, it was determined that the facility failed to provide the recommended pneumococcal immunizations for two of five residents reviewed for immunizations (Residents 18 and 37).
Findings include:
The policy entitled Infection Control-Immunization of pneumococcal vaccination of residents last reviewed September 20, 2023, indicates that all residents upon admission are offered the Pneumococcal vaccine, consent or declination will be maintained on the resident record. If a PCV15 (Pneumococcal conjugate vaccine) is used, this should be followed by a dose of PPSV23 (Pneumococcal polysaccharide vaccine) one year later. Prior administration of Pneumococcal vaccine shall be documented on the resident immunization record. Vaccines are administered per the CDC (Center for Disease Control) guidance as follows: Residents 19-[AGE] years old considered at risk, or 65 or older with one dose of PCV15 should be followed up with a dose of PPSV23 at least one year after the PCV15.
Review of Resident 18's clinical record revealed that the facility admitted her on October 5, 2018. The facility provided a pneumococcal history of Resident 18 after the surveyors questioning. Resident 18's history revealed that she received the PCV15 before admission. There was no documented evidence in Resident 18's clinical record to indicate that the facility offered the PPSV23 to Resident 18 as recommended by the CDC for residents over [AGE] years of age.
Review of Resident 37's clinical record revealed that the facility admitted him on November 17, 2020. The facility provided a pneumococcal history of Resident 37 after the surveyors questioning. Resident 37's history revealed that he received the PCV15 in 2011, before admission. There was no documented evidence in Resident 37's clinical record to indicate that the facility offered the PPSV23 to Resident 37 as recommended by the CDC for at risk individuals.
Interview with Employee 1, infection control preventionist, on December 7, 2023, at 12:30 PM confirmed the above findings for Resident 18 and 37.
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)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for three of three residents reviewed...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to provide services to maintain a resident's range of motion (ROM) for three of three residents reviewed (Residents 54, 67, and 72).
Findings include:
Clinical record review for Resident 25 revealed a current care plan for staff to provide level two nursing rehabilitation of AROM (active range of motion, movement of the body in an attempt to maintain a resident's ability) to the RLE (right lower extremity) and PROM (passive range of motion) to the LLE (left lower extremity) for two sets of 15 repetitions in all planes daily and orange TheraBand (a stretchy band to help increase mobility) AROM to the RUE (right upper extremity) and PROM to the LUE (left upper extremity) two sets of 15 repetitions in all planes daily.
Review of task documentation for Resident 25 for October, November, and December 2023, revealed that staff did not document completion of the restorative task on the following dates:
AROM RLE and PROM LLE-
October 21, 22, 27, and 31, 2023
November 1, 2, 3, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 17, 18, 21, 23, 24, 26, 27, 28, and 29, 2023
December 2, 3, and 4, 2023
AROM RUE and PROM LUE-
October 21, 22, 27, and 31, 2023
November 1, 2, 3, 5, 6, 7, 9, 10, 11, 12, 13, 14, 15, 17, 18, 20, 21, 23, 24, 26, 27, 28, and 29, 2023
December 2, 3, and 4, 2023
Clinical record review for Resident 72 revealed a current care plan for staff to provide level two nursing rehabilitation of PROM to the RUE for two sets of 15 repetitions with slow stretch and hold at end range to all planes daily, PROM to BLE (bilateral lower extremities) for 10 repetitions (leg out to side, leg in across middle, knee kick hold each and end range for 10 seconds) daily, and sit to stand 8 to 10 times with a one assist quad cane daily.
Review of task documentation for Resident 72 for October, November, and December 2023, revealed that staff did not document completion of the restorative task on the following dates:
PROM RUE and PROM BLE-
October 21, 27, and 31, 2023
November 1, 2, 6, 9, 10, 12, 14, 19, 24, 26, and 27, 2023
December 2, 3, 4 and 5, 2023
Sit to Stand-
October 21, 27, and 31, 2023
November 1, 2, 6, 9, 10, 12, 14, 19,23, 24, 26, and 27, 2023
December 2, 3, 4 and 5, 2023
The surveyor reviewed the above information on December 6, 2023, at 1:30 PM, and December 7, 2023, at 1:30 PM with the Nursing Home Administrator and Director of Nursing.
Clinical record review for Resident 54 revealed a current care plan for her to receive level II restorative sit to stand at the handrail in the hallway for 5-7 repetitions.
Review of the task documentation from November 1-December 7, 2023, revealed that Resident 54 did not receive the level II restorative programs on the following dates:
November 4, 5, 10, 14, 17, 18, 19, 20, 23, 24, 25, and 28, 2023.
December 1 and 4, 2023.
Interview with the Nursing Home Administrator and Director of Nursing on December 7, 2023, at 2:16 PM confirmed the above noted findings related to Resident 54's sit to stand level II restorative program.
The facility failed to provide services to increase or prevent a decline in a resident's ROM or mobility for Residents 54, 67, and 72.
483.25(c)(1)-(3) Increase/prevent Decrease In Rom/mobility
Previously cited 1/27/23
28 Pa. Code 211.10(a)(c)(d) Resident care policies
28 Pa. Code 211.12(c)(d)(1)(3)(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 review and staff interview, it was determined that the facility failed to ensure that a resident received acceptable parameters of hydration for one of one resident reviewed (...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident received acceptable parameters of hydration for one of one resident reviewed (Resident 97).
Findings include:
Clinical record review for Resident 97 revealed the facility admitted him on September 26, 2023. On September 26, 2023, the physician ordered a fluid restriction of 1500 milliliters (ml) per day. On December 4, 2023, the physician changed the fluid restriction to 1800 ml per day.
Review of Resident 97's care plan dated October 4, 2023, revealed he was at risk for a fluid-volume overload (making it harder for heart to pump when there is a fluid overload) related to congestive heart failure (chronic condition in which the heart doesn't pump blood as well as it should).
The facility failed to verify what Resident 97's fluid intake totals were for each 24-hour period to determine if Resident 97 was within his restriction or getting enough fluids. The surveyor totaled Resident 97's fluid intakes from November 1-30, 2023, and December 1-7, 2023, which revealed the following 24-hour fluid intake over all three shifts that indicated Resident 97 was not meeting his assessed daily fluid needs or exceeding his assessed daily fluid needs:
November 1, 2023 - 720 ml
November 4, 2023 - 2400 ml
November 7, 2023 - 3120 ml
November 8, 2023 - 2400 ml
November 9 - 13, 2023 - no fluids recorded.
November 14, 2023 - 360 ml
November 15, 2023 - 720 ml
November 16, 2023 - 120 ml
November 17, 2023 - 200 ml
November 18, 2023 - 180 ml
November 19, 2023 - 160 ml
November 20, 2023 - 180 ml
November 21, 2023 - 120 ml
November 22, 2023 - 160 ml
November 23, 2023 - no fluids recorded.
November 24, 2023 - 240 ml
November 25, 2023 - 240 ml
November 26, 2023 - 360 ml
November 27, 2023 - 120 ml
November 28, 2023 - 320 ml
November 29, 2023 - 440 ml
November 30, 2023 - 960 ml
December 1, 2023 - 1640 ml
December 2, 2023 - 1520 ml
December 3, 2023 - 200 ml
December 4, 2023 - 2720 ml
December 5, 2023 - 2360 ml
December 7, 2023 - 2920 ml
During a meeting on December 8. 2023, at 10:56 AM with the Director of Nursing, it was confirmed that the facility did not monitor Resident 97's fluid intake to ensure adherence to fluid restrictions and adequate fluid intake.
483.25(g)(1)-(3) Nutrition/hydration Status Maintenance
Previously cited 1/27/23
28 Pa Code 211.12(d)(1)(3)(5) Nursing services
MINOR
(B)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident or resident representative in writing of a transfer to the hospital for seven of 10...
Read full inspector narrative →
Based on clinical record review and staff interview, it was determined that the facility failed to notify a resident or resident representative in writing of a transfer to the hospital for seven of 10 residents reviewed (Residents 23, 25, 74, 97, 102, 106, and 123).
Findings include:
Clinical record review revealed that Resident 23 was transferred to an acute care hospital on December 5, 2023, where he was admitted . Further clinical record review revealed that no written notification was provided to Resident 23's responsible party regarding the transfer that included the required contents: reason for the transfer, effective date of the transfer, location to which the resident was transferred to, a statement of the resident's appeal rights, contact and address information for the Office of the State Long-Term Care Ombudsman, and information for the agency responsible for the protection and advocacy of individuals with developmental disabilities.
Clinical record revealed that Resident 97 was transferred to an acute care hospital on October 20, 2023, where he was admitted . Further clinical record review revealed that no written notification was provided to Resident 97's responsible party regarding the transfer that included the required contents as listed above.
Clinical record revealed that Resident 102 was transferred to an acute care hospital on September 18, 2023, where she was admitted . Further clinical record review revealed that no written notification was provided to Resident 102's responsible party regarding the transfer that included the required contents as listed above.
Clinical record review for Resident 74 revealed that he was transferred to an acute care hospital on November 3, 2023, where he was admitted . Further clinical record review revealed that no written notification was provided to Resident 74 or his responsible party regarding the transfer that included the required contents as listed above.
Clinical record review for Resident 123 revealed that he was transferred to an acute care hospital on December 2, 2023, where he was admitted . Further clinical record review revealed that no written notification was provided to Resident 123 or his responsible party regarding the transfer that included the required contents as listed above.
Interview with the Nursing Home Administrator on December 5, 2023, at 12:45 PM revealed that the facility did not provide the above residents' responsible parties with the required written notice of transfer.
Clinical record review for Resident 106 revealed that they were transferred to the hospital on November 3, 10, and 14, 2023, after there was a change in their condition.
There was no documentation that the facility provided written notification to the resident or their responsible party that included the required contents as listed above.
Clinical record review for Resident 25 revealed that they were transferred to the hospital on November 2, 2023, after there was a change in their condition. There was no documentation that the facility provided written notification to the resident or their responsible party that included the required contents as listed above.
The surveyor reviewed the above information for Residents 106 and 25 during an interview with the Nursing Home Administrator on December 8, 2023, at 9:45 AM.
28 Pa. Code 201.29(a) Resident rights
28 Pa. Code 201.14 (a) Responsibility of license
Jan 2023
12 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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the resident's ability to use a call ...
Read full inspector narrative →
Based on clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the resident's ability to use a call bell for one of 22 residents reviewed (Resident 88).
Findings include:
Social service documentation dated December 29, 2022, at 3:25 PM revealed that the social worker met with Resident 88 in her new room. The resident voiced no concerns/complaints regarding her room and appeared content at the time. Staff will continue to monitor mood, behavior, and normal routine.
Observation of and interview with Resident 88 on January 24, 2023, at 10:48 AM revealed the resident was sitting in an upholstered chair and she wanted to go to bed because she was having pain in her low back. The surveyor asked her to ring her call bell to summon the staff. Resident 88 reached for her call bell and was unable to push the red button to ring the bell.
The surveyor immediately left the resident's room and found Employee 2, nurse aide, in the hallway and Employee 2 and Employee 3, nurse aide, entered Resident 88's room to transfer her in bed with a mechanical full body lift.
Observation of and interview with Employee 5, licensed practical nurse, on January 24, 2023, at 11:05 AM revealed Employee 5 changed Resident 88's call bell to a squeeze type call bell. The resident provided a return demonstration that showed she could use the call bell. Employee 5 indicated that the squeeze type bells were present on the unit where Resident 88 lived prior to the room change.
Further interview with Employee 5 on January 24, 2023, at 1:14 PM revealed that maintenance is changing the push type call bells for the squeeze type call bells for the other residents that were moved from the third floor when it closed as the residents were accustomed to that type of call bell.
During an interview with the Nursing Home Administrator and Director of Nursing on January 26, 2022, at 1:45 PM it was confirmed that Resident 88 was moved to another floor almost a month ago and could not use the call bell provided to her.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
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 clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to ensure assessments accurately reflected residents' status for two of 22 residents reviewed (Residents 20 and 29).
Findings include:
Clinical record review for Resident 29 revealed a quarterly MDS (Minimum Data Set, an assessment tool completed at specific intervals to determine resident care needs) dated December 3, 2022, in which facility staff assessed the resident as receiving an anticoagulant seven days in the assessment period.
Further clinical record review revealed no evidence that Resident 29 received an anticoagulant during the assessment period for the MDS noted above.
An interview with the Director of Nursing (DON) on January 26, 2023, at 2:15 PM confirmed that Resident 29 did not receive an anticoagulant in the assessment period and it was coded incorrectly.
Clinical record review for Resident 20 revealed an admission MDS assessment dated [DATE], that indicated Resident 20 received an anticoagulant medication on seven days during the assessment period.
Resident 20's clinical record contained no evidence that her physician ordered, or that she received, an anticoagulant medication as the above assessment indicated.
Interview with Employee 10 (licensed practical nurse assessment coordinator) on January 27, 2023, at 12:32 PM confirmed that the MDS assessment that indicated Resident 20 received an anticoagulant medication was completed in error.
28 Pa. Code 211.5(f) Clinical records
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding nail care and weight monitoring for two ...
Read full inspector narrative →
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide the highest practicable care regarding nail care and weight monitoring for two of 22 residents reviewed (Residents 95 and 14).
Findings include:
Review of Resident 95's clinical record revealed nursing documentation dated December 21, 2022, at 12:52 PM that indicated the facility's wound nurse was in the room with the facility's nurse practitioner and Resident 95's fourth and fifth fingernails on her right hand were thick, yellow, and raised above her nail beds. The note indicated that a referral was being sent for podiatry to evaluate the fingernails for possible grinding or avulsion (removal). It also referenced wound healing solutions note for full details.
Review of Resident 95's Wound Healing Solutions consult dated December 21, 2022, indicated that they were seeing Resident 95 for issues with her fourth and fifth fingernails on her right hand. The report states that nursing staff had been treating her thickened nails with Lotrimin (used for fungal infections) cream without any improvement. Wound healing solutions described Resident 95's nails as thickened raised yellow nail plates and to consult podiatry.
Review of Resident 95's podiatry consult dated January 12, 2023, indicated that her toenails were assessed and treated, but there was no documented evidence in the podiatry consult that indicated her fingernails were assessed or treated.
Interview with the Administrator on January 26, 2023, at 9:44 AM confirmed the above findings for Resident 95.
Review of a hospital discharge summary for Resident 14 dated January 7, 2023, revealed the resident was treated for an exacerbation of heart failure (a flare-up of the heart not pumping blood normally causing shortness of breath, fatigue, rapid heartbeat, and fluid build-up in the body) and received intravenous diuresis (medications given through the vein to reduce fluid in the body).
Further review of the hospital discharge summary for Resident 14 revealed the resident was discharged on Lasix (diuretic, to reduce fluid in the body) 40 mg (milligrams) per day. Daily weights were to continue, and if weight increases by two pounds in one day or three pounds in two days with worsening shortness of breath or worsening leg edema (swelling), take an additional dose of Lasix 40 mg every afternoon.
Review of a cardiology (doctor specializing in the heart) consult dated January 10, 2023, revealed the resident was to be weighed daily.
The surveyor requested documentation of daily weights for Resident 14 for January 7, 2023, to current from the Nursing Home Administrator on January 25, 2023, at 12:35 PM.
Clinical record review for Resident 14 revealed a weight summary, which revealed the resident was not weighed daily. Resident 14 was weighed on the following dates since readmission:
January 10, 2023, weighed 191.6 pounds
January 26, 2023, weighed 207.8 pounds.
During an interview with the Nursing Home Administrator and Director of Nursing on January 26, 2023, it was confirmed that daily weights were not performed and monitored for Resident 14.
28 Pa. Code 211.10(c)(d) Resident care policies
28 Pa. Code 211.12(d)(1)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions for range of motion treatment for one of three residents review...
Read full inspector narrative →
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions for range of motion treatment for one of three residents reviewed (Resident 45).
Findings include:
Review of Resident 45's clinical record revealed instructions dated April 27, 2022, from the therapy department to perform passive range of motion to Resident 45's upper and lower extremities. After completing the passive range of motion, staff are to apply a blue hand roll to Resident 45's right hand and a built-up palm guard to his left hand for six hours. These instructions were communicated to nursing staff using a communication form and the task list.
Observation of Resident 45 on January 24, 2023, at 10:46 AM revealed he was lying in bed. Both hands were contracted, and there were no visible devices in his hands to help with the contractures.
Observation of Resident 45 on January 24, 2023, at 11:47 AM revealed he was out of bed and in a reclining geri-chair. There were still no devices in his hands visible to help with the contractures.
Observation of Resident 45 on January 24, 2023, at 12:31 PM and again at 1:07 PM revealed he still did not have any devices in his hands visible to help with his contractures.
Interview with Employee 1, nurse aide, on January 24, 2023, at 1:23 PM revealed that Resident 45 is on her assignment today and that she completed his passive range of motion earlier this morning. Employee 1 indicated that she didn't think to put on Resident 45's devices for his hands. Observation of Resident 45's room with Employee 1 at this time revealed that his hand devices were not available in his room.
Interview with the Administrator on January 26, 2023, at 9:42 AM, acknowledged the above findings for Resident 45.
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to maintain ...
Read full inspector narrative →
Based on review of select facility policies and procedures, observation, clinical record review, and staff interview, it was determined that the facility failed to implement interventions to maintain acceptable parameters of nutrition for one of 11 residents reviewed for nutrition concerns (Resident 84).
Findings include:
The Weight Policy, last reviewed without changes on July 31, 2022, revealed that it is the policy of the facility to weigh all residents on admission, re-admission, weekly, monthly, or as deemed necessary per physician orders. A significant weight loss is defined as five percent weight change in 30 days, 7.5 percent weight change in 90 days, or 10 percent weight change in 180 days. Residents scheduled to be weighed monthly will be weighed by the 10th of the month. If the resident exhibits a weight change of five pounds from the previous weight in the weight report, the resident will be re-weighed within 24 hours and the re-weight will be recorded. The registered dietitian or diet tech should then strike out the previous weight to identify that a re-weight was obtained and verified. Weights will be documented in the kiosk.
Clinical record review for Resident 84 revealed social services documentation dated January 23, 2023, at 11:42 AM that an interview assessed Resident 84 was able to make himself understood and that he was able to understand others; and his score on the Brief Interview for Mental Status (BIMS) was 15 out of a possible 15, which indicated that he was cognitively intact.
Observation of and interview with Resident 84 on January 24, 2023, at 11:55 AM revealed that he appeared thin. Resident 84 pointed to a raised area on his right chest/abdominal area and stated to the surveyor that it was his rib protruding due to his thin frame. Resident 84 claimed that his weight was, in the 120s (pounds of weight).
Nutritional progress documentation by a dietary tech dated November 18, 2022, at 11:52 AM noted that Resident 84's weight had been noted to trend downwards over the past six months. The writer indicated that there would be a change in the nutritional supplement provided to Resident 84 as per his request. The writer indicated that she would continue to visit with Resident 84 at mealtimes to encourage intake of meals, supplements, and fluids served. Monitoring and goals included to monitor Resident 84's appetite at meals and review his weight status as needed.
Resident 84's clinical record contained no evidence of progress note documentation by the dietary staff after November 18, 2022, until January 18, 2023.
Resident 84's clinical record revealed the following weight assessments:
June 7, 2022, 142.2 pounds
July 6, 2022, 138.8 pounds
August 3, 2022, 137 pounds
September 6, 2022, 136.2 pounds
October 3, 2022, 135.6 pounds
November 9, 2022, 131.6 pounds
No evidence of a weight assessment in December 2022
January 13, 2023, 124.2 pounds (a 7.4 pound, 5.6 percent loss in two months; an 11.4 pound, 8.4 percent loss in three months; and a 14.6 pound, 10.51 percent loss in six months)
There was no evidence that staff obtained a re-weight assessment within 24 hours (per the facility policy) when Resident 84's weight reflected a greater than five pound weight change from the previously recorded weight on January 13, 2023.
Nutritional progress documentation dated January 18, 2023, at 2:41 PM acknowledged Resident 84's weight assessment on January 13, 2023, reflected significant changes in two months, three months, and six months; however, did not identify that staff failed to obtain a re-weight assessment. There was no indication that the writer instructed nursing staff to obtain a weight assessment at that time.
A weight assessment recorded on January 23, 2023, indicated Resident 84 lost another one-half pound and was now 123.7 pounds.
Interview with Employee 7 (dietitian) on January 26, 2023, at 1:28 PM confirmed that there was no weight assessment in December 2022 for Resident 84. Employee 7 indicated that unofficial paperwork that does not become part of the clinical record indicated that Resident 84 refused a weight assessment at some point; however, there was no date or staff signature to indicate when this occurred. Employee 7 confirmed that this information was not reflected in Resident 84's clinical record in December 2022. Employee 7 also confirmed that there was no evidence that either she or the diet tech re-assessed Resident 84 after the change in his nutritional supplementation on November 18, 2022, to evaluate the effectiveness of the interventions towards established goals. The interview confirmed that the next documented review of Resident 84's nutritional status occurred following the January 18, 2023, significant weight loss assessment.
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility failed to properly store resident medications and ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility failed to properly store resident medications and biologicals on one of three nursing units reviewed (Second Floor [NAME] Nursing Unit).
Findings include:
Observation of the Second Floor [NAME] Nursing Unit with Employee 6, licensed practical nurse, on [DATE], at 9:30 AM revealed a treatment cart with adhesive remover that expired in [DATE]. There was also a bottle of Dakin's Wound Cleanser Solution that was stored horizontally and leaking in the top drawer.
A refrigerator used to store resident medications was observed. Medications that were currently being stored in the refrigerator included: multiple Trulicity insulin pens (an injected medication used to control blood sugar levels); multiple vials of Humalog (a type of insulin injected into the body to help control blood sugar levels); Lantus (a type of insulin injected into the body to help control blood sugar levels); and eight Tresiba insulin pens (a type of insulin injected into the body to help control blood sugar levels).
The current facility temperature log attached to the front of the refrigerator revealed the following dates did not have temperatures documented: [DATE], 7, 8, 9, 18, 20, and 21, 2023. Employee 6 revealed that night shift is responsible for documenting the temperatures daily and was unsure why the temperatures were not documented. The current temperature of the refrigerator per the thermometer indicated 30 degrees Fahrenheit.
Further review of the temperature log revealed the following temperatures in Fahrenheit logged by staff for 2023:
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
[DATE] degrees
These documented temperatures were outside of the parameters of the manufacturer's established guidelines for storage temperatures for several of the medications being stored.
Per prescribing information dated 2022, revealed that unused Tresiba, Trulicity, Humalog, and Lantus should be stored in a refrigerator between 36 degrees Fahrenheit to 46 degrees Fahrenheit. None of the medications should be frozen.
The above findings were discussed in a meeting with the Nursing Home Administrator and Director of Nursing on [DATE], at 2:00 PM.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(i) Pharmacy services
28 Pa. Code 211.12(d)(1) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide professional dental services for one of two residents reviewed for...
Read full inspector narrative →
Based on observation, clinical record review, and resident and staff interview, it was determined that the facility failed to provide professional dental services for one of two residents reviewed for dental concerns (Resident 42).
Findings include:
Observation of and interview with Resident 42 on January 24, 2023, at 12:29 PM revealed that she had numerous missing natural teeth. Resident 42 stated that she had a history of several dental fillings falling out. Resident 42 stated that a dentist was going to repair her teeth, but the COVID pandemic occurred, and she was not sure what the plan was at this time.
Clinical record review for Resident 42 revealed that a dental hygienist provided services on August 11, 2022, that included prophylactic cleaning. The provider confirmed that Resident 42 had missing teeth and a retained root (the portion of the tooth that anchors it in the jawbone, contains the soft tissue that provides nutrients and nerves to the tooth). The documentation indicated that the dentist was not present on this date.
Documentation by the facility's contracted dentist dated September 27, 2022, confirmed that Resident 42 had defective restorations (fillings) and that the plan was to extract a simple erupted (visible) root.
Resident 42's clinical record contained no evidence that the dentist performed the extraction service that date or returned to the facility to provide Resident 42 services since that date.
Documentation by the dental hygienist dated December 19, 2022, indicated that Resident 42 received prophylactic cleaning; however, that the dentist was not present on this date.
The surveyor requested evidence of Resident 42's professional dental services via email communication to the Nursing Home Administrator on January 25, 2023, at 3:12 PM.
The surveyor requested evidence that the facility's contracted dentist provided services to Resident 42 after the determination on September 27, 2022, that she required the extraction of an exposed dental root during an interview with the Nursing Home Administrator and the Director of Nursing on January 26, 2023, at 1:30 PM.
Interview with the Nursing Home Administrator on January 27, 2023, at 11:56 AM confirmed that the facility had no evidence that the dentist attempted to provide services to Resident 42 in the approximate four months since September 27, 2022.
Interview with the Nursing Home Administrator on January 27, 2023, at 12:05 PM revealed that, in response to the surveyor's questioning, the consulting facility dentist altered his original documentation dated September 27, 2022, to now indicate that the plan to extract the root was going to be PRN (as needed).
28 Pa. Code 211.15(a) Dental services
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0840
(Tag F0840)
Could have caused harm · This affected 1 resident
Based on observation and resident and staff interview, it was determined that the facility failed to arrange for hair styling services for one of 22 residents reviewed (Resident 84).
Findings include:...
Read full inspector narrative →
Based on observation and resident and staff interview, it was determined that the facility failed to arrange for hair styling services for one of 22 residents reviewed (Resident 84).
Findings include:
Interview with Resident 84 on January 24, 2023, at 11:58 AM revealed that the nurse aide trims his beard; however, he had not had his hair cut since he, was here, but that he would like to have his hair cut. Resident 84's hair appeared long enough to drape over his ears.
Clinical record review for Resident 84 revealed an authorization form signed by Resident 84's responsible party on April 15, 2021, that hair cutting services were desired while residing at the facility.
The surveyor requested that the facility provide evidence that outside resources (or appropriate provider services) for hair cutting were arranged for Resident 84 via email communication to the Nursing Home Administrator on January 25, 2023, at 3:12 PM.
Beauty/Barber Shop weekly schedule documentation provided by the facility indicated that Resident 84 received hair cutting services on January 12, 2022, and April 26, 2022. There was no evidence that Resident 84 received hair cutting services for the nine months since April 26, 2022.
Social service documentation dated January 25, 2023, at 5:01 PM (following the surveyor's questioning) revealed that the writer spoke with the facility's beautician, and she advised that Resident 84 was at the beauty shop that day and had his hair cut. The documentation indicated that Resident 84 enjoyed the visit.
28 Pa. Code 201.21(b) Use of outside resources
28 Pa. Code 211.12(d)(3) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection during a dressing change for one of two reside...
Read full inspector narrative →
Based on observation and staff interview, it was determined that the facility failed to ensure an environment free from the potential spread of infection during a dressing change for one of two residents observed for dressing changes (Resident 88).
Findings include:
Review of a nursing progress note for Resident 88 dated December 14, 2022, at 4:41 PM revealed that the resident was readmitted from the hospital with a deep tissue injury (caused by pressure to the area under the skin, that causes tissue to die) to the coccyx (area of tailbone) that was not opened and dark in color.
Review of the wound consultation for Resident 88's new wound dated December 21, 2022, revealed that the resident was readmitted from the hospital with a Stage III pressure ulcer/injury (full thickness tissue loss, subcutaneous fat may be visible) of the coccyx that measured 0.7 cm (centimeter) length by 0.5 cm width by 0.2 cm depth.
Review of a current physician's order for Resident 88 initiated January 5, 2023, instructed the nurse to cleanse the coccyx wound with Dakin's Solution 1/4 strength (diluted solution used to cleanse wounds to prevent infection) topically every day, apply skin prep (protective barrier) to the peri-wound (the skin round the pressure ulcer), apply collagen AG (an advance wound care dressing to promote healing) to the wound base, and cover with a composite dressing (an absorbent fabric dressing).
Review of a nursing progress note for Resident 88 dated January 19, 2023, revealed that the resident had a blister (fluid filled sac) on her back that measured 1.5 cm by 1 cm.
Review of a physician's order for Resident 88 initiated January 19, 2023, instructed the nurse to cleanse the mid-back fluid filled blister sac with NSS (Normal Saline Solution, like normal body fluid), pat dry, and apply skin prep three times daily.
Observation on January 24, 2023, at 11:16 AM revealed Employee 5, licensed practical nurse, performed a dressing change to Resident 88's coccyx. After Employee 5 removed the soiled dressing from the resident's coccyx, she cleansed the area with Dakin's Solution. Employee 5 changed her soiled gloves and completed the dressing change to the coccyx. After completing the dressing change to the coccyx, Employee 5 changed her gloves and cleansed the mid-back area with NSS and applied skin prep as ordered. The blister was no longer present on the mid-back. The area was red and open.
Employee 5 did not cleanse her hands with hand sanitizer or wash with soap and water after removing the soiled dressing and before applying clean gloves to administer the treatment and clean dressing to the coccyx wound. Employee 5 did not sanitize or cleanse her hands before moving on to the next treatment of the mid-back wound. Employee 5 assisted Resident 88 turning in bed without performing hand hygiene.
Employee 5 proceeded to leave Resident 88's room and returned items to the treatment cart without performing hand hygiene. Employee 5 proceeded to the shower room to wash her hands at the sink and turned off the water with her bare hand rather than using a paper towel to touch the faucet.
The surveyor discussed the above breaks in infection control with Employee 5 on January 24, 2023, at 11:29 AM.
The above information was brought to the attention of the Director of Nursing on January 27, 2023, at 10:25 AM.
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0888
(Tag F0888)
Could have caused harm · This affected 1 resident
Based on a review of the Centers for Medicare and Medicaid directives, select facility policies and procedures, employee vaccination data, and staff interview, it was determined the facility failed to...
Read full inspector narrative →
Based on a review of the Centers for Medicare and Medicaid directives, select facility policies and procedures, employee vaccination data, and staff interview, it was determined the facility failed to ensure that all staff were fully vaccinated for COVID-19, except for those granted exemption status as recommended by the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines (Employee 4).
Findings include:
The Center for Clinical Standards and Quality/Quality, Safety and Oversight Group, CMS, QSO-23-02 memo, dated October 26, 2022, stated that Medicare and Medicaid-certified facilities are expected to comply with all applicable regulatory requirements; and that CMS expects all providers' and suppliers' staff to have received the appropriate number of doses of the primary vaccine series unless exempted as required by law, or delayed as recommended by the CDC. Facility staff vaccination rates under 100 percent constitute noncompliance under the rule.
A review of a facility policy entitled, Infection Control COVID-19 Vaccine Residents and Staff, last revised September 2022, revealed that staff members are required to have completed the primary vaccine series as a condition of employment. Staff that choose to not be vaccinated are referred to human resources for additional information and action including submission of a waiver for approval.
Review of the facility's employee vaccination status information revealed that as of January 24, 2023, only 99.5 percent of staff were either fully vaccinated, granted a qualifying exemption, or identified as having a temporary delay recommended by the CDC. There was currently one staff that had not been fully vaccinated and without an appropriate exemption or temporary delay.
Review of Employee 4's personnel record indicated that the facility hired her on October 17, 2022. Review of Employee 4's time card indicated that she worked three days in October 2022, 14 days in November 2022, and five days in December 2022. Review of Employee 4's vaccination status information revealed that Employee 4 was not fully vaccinated for COVID-19. The available information indicated that Employee 4 received one dose of the Pfizer COVID-19 vaccination on September 14, 2021; however, there was no evidence that Employee 4 completed the COVID-19 vaccination series or obtained an exemption from vaccination.
Interview with the Nursing Home Administrator, the Director of Nursing, and Employee 9 (infection preventionist) on January 26, 2023, at 1:30 PM confirmed that the facility permitted Employee 4 to work while she was not fully vaccinated for COVID-19, was not granted a medical or religious exemption, and was not qualified for an approved temporary delay for the vaccination.
483.80(i)(1)-(3)(i)-(x) COVID-19 Vaccination of Facility Staff
Previously cited deficiency 3/30/22
28 Pa. Code 201.14(a) Responsibility of Licensee
28 Pa. Code 201.18(b)(1)(3)(d)(e)(1) Management
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies, and resident and staff interview, it was determined that th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of select facility policies, and resident and staff interview, it was determined that the facility failed to identify and assess a resident's decline in activities of daily living (ADL) for one of three residents reviewed for an ADL decline (Resident 75), failed to complete a restorative nursing program for one of three residents reviewed for activities of daily living concerns (Resident 33), and failed to ensure resident hearing aids for one of two residents reviewed for sensory devices (Resident 23).
Findings include:
The facility policy entitled Activities of Daily Living, last reviewed without changes on July 31, 2022, revealed residents will be screened/rescreened for ADL function on admission, readmission, quarterly, and with significant changes in functional status. The interdisciplinary team will evaluate changes in functional status. Changes in condition will be assessed by the interdisciplinary team and referrals for rehabilitation consults and restorative nursing programs will be communicated via the alert system. A plan of care will be implemented to maintain, improve, or prevent/minimize declines in functional status.
Review of Resident 75's MDS (Minimum Data Set, assessment completed at specific intervals to determine care needs) assessment dated [DATE], noted nursing staff assessed Resident 75 as independent requiring no staff assistance for bed mobility or transfers. Review of Resident 75's next quarterly assessment dated [DATE], revealed nursing staff assessed Resident 75 as only requiring supervision with no staff assistance for bed mobility and transfers.
Review of Resident 75's most recent quarterly assessment dated [DATE], revealed nursing staff assessed Resident 75 as declining and requiring extensive assistance of one staff for transfers and limited assistance of one staff for bed mobility.
There was no documented evidence in Resident 75's clinical record to indicate that the facility identified or assessed Resident 75's decline in her ability to perform these activities of daily living.
The surveyor reviewed the above findings for Resident 75 during an interview with the Director of Nursing on January 27, 2023, at 10:06 AM. The facility was unable to provide any further documentation that the facility assessed Resident 75's decline in bed mobility and transfers.
Clinical record review for Resident 33 revealed an annual MDS assessment dated [DATE], that assessed him as independent following setup assistance only for his bed mobility; and that he was independent for transfers.
A quarterly MDS assessment dated [DATE], assessed a decline in Resident 33's activities of daily living functioning to include the physical assistance of one staff for both bed mobility and transfers.
A restorative nursing program (RNP) established August 21, 2021, instructed staff to ambulate Resident 33 with one assistance and a rolling walker 100 to 200 feet every shift.
Review of electronic documentation used to record the completion of Resident 33's RNP program dated November 27, 2022, through January 25, 2023, revealed that staff repeatedly documented, Not Applicable, for dates that indicated that the program did not occur. Staff failed to complete the program at least twice a day with Resident 33 on the following dates:
November 27, 28, 29, 30, 2022
December 2, 4, 5, 6, 8, 9, 10, 13, 15, 16, 17, 18, 19, 20, 21, 23, 26, 28, 29, 30, 31, 2022
January 1, 2, 6, 8, 11, 15, 16, 19, 20, 21, and 24, 2023
Interview with the Director of Nursing on January 26, 2023, at 11:30 AM, and January 27, 2023, at 10:15 AM confirmed that the available documentation does not support that nursing staff completed the restorative nursing program for Resident 33 at least twice daily for the dates reviewed. The documentation entries of, Not applicable, were not appropriate as this resident resided at the facility (was not hospitalized ) during the dates reviewed.
Observation of and interview with Resident 23 on January 24, 2023, at 12:45 PM revealed the resident was fully dressed and sitting in a wheelchair in her room eating lunch. The resident told the surveyor she could not hear. The resident was not wearing hearing aids. A handwritten sign was on the wall behind the resident's wheelchair to remind staff to put in the resident's hearing aids each morning.
On January 24, 2023, at 12:49 PM the surveyor was outside Resident 23's room and observed Employee 8, licensed practical nurse, enter the resident's room carrying hearing aids and say to the resident that she brought them in earlier, but you were in the activity this morning.
Observation of Resident 23 on January 26, 2023, at 9:15 AM revealed she was fully dressed and sitting in a wheelchair in her room and not wearing hearing aids.
The surveyor reviewed the findings for Resident 23 during an interview with the Director of Nursing on January 26, 2023, at 2:10 PM.
Observation of and interview with Resident 23 on January 27, 2023, at 9:33 AM revealed the resident was fully dressed and sitting in the wheelchair in her room and not wearing hearing aids. Resident 23 made hand gestures pointing to her ears and said, Yes, I want them in.
The surveyor reviewed the additional findings for Resident 23 during an interview with the Director of Nursing on January 27, 2023. It was also revealed that the nurse stores and inserts the hearing aids for Resident 23 as they were lost at one time.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff intervie...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policies and procedures, clinical record review, observation, and resident and staff interview, it was determined that the facility failed to assess entrapment risk and obtain consent for the use of bed rails for three of six residents reviewed for accident hazards (Residents 16, 55, and 84).
Findings include:
Observation of Resident 16's bed on January 24, 2023, at 11:50 AM revealed right and left enabler bars secured to her bed. Concurrent interview with Resident 16 revealed that she uses the enabler bars to turn herself.
Clinical record review for Resident 16 revealed a physician's order dated November 30, 2022, for the resident to have left and right enablers on the bed to improve bed mobility independence.
Review of a Bed Safety with Measuring Tool for Resident 16 dated December 1, 2022, revealed the resident would benefit from an enabler bar to improve independent bed mobility.
Review of an Enabler/Side Rail Consent form signed by Resident 16 on December 2, 2021, revealed the resident signed for a left enabler bar.
Review of an Enabler/Side Rail Consent form signed by Resident 16 on December 1, 2022, revealed the resident signed for a right enabler bar.
The facility failed to obtain a clear and current consent listing bilateral (one on each side) enabler bars and failed to include in the bed safety assessment the need for bilateral enabler bars.
During an interview with the Director of Nursing on January 27, 2023, at 10:15 AM confirmed that the current consent for enabler bars only lists the right enabler bar. The Director of Nursing indicated that the facility already had a consent for the left enabler bar which was signed in 2021. The Director of Nursing also indicated the Bed Safety Measuring Tool does not include the use of two bedrails as an option to check on the computerized form and there is no other documentation listing that the resident was assessed for two enabler bars.
The facility policy entitled, Side Rails/Enablers, last reviewed without changes on July 31, 2022, revealed that Bed Safety/Physical Device/Alarm Evaluation is completed once side rails/enablers are placed by maintenance. All information is completed, and measurements are entered. Side rail/enablers are reviewed no less than quarterly by the administrative assistance or designee.
Clinical record review for Resident 55 revealed a physician's order dated January 19, 2023, for him to have a right-sided enabler bar.
Observation of Resident 55's room on January 26, 2023, at 12:56 PM, revealed an enabler device secured to the right side of his bed.
A Bed Safety Measurement assessment completed January 19, 2023, indicated that the staff who completed the assessment noted that the safety measurements for Zone 4 (the area under the rail at the ends of the rail) was not applicable. The measurements entered for Zone 1 (within the rail which, according to the form, are to be no more than 4.5 inches) were recorded as four inches by six inches.
Interview with the Director of Nursing on January 27, 2023, at 10:15 AM confirmed that an entry of, N/A (not applicable), would not be acceptable for Resident 55's Zone 4 as there is a bottom of a rail that would need assessed in relation to the top of the mattress.
Observation of Resident 84's room on January 24, 2023, at 12:06 PM revealed enabler devices secured to the head of his bed bilaterally.
Clinical record review for Resident 84 revealed a physician's order active since October 29, 2021, for the use of a right and left side enabler device on his bed.
Review of Resident 84's census information revealed that his bed assignment changed on the following dates:
April 30, 2021
August 31, 2022
September 6, 2022
December 7, 2022
December 29, 2022
Review of Bed Safety/Physical Device/Alarm Evaluation assessments provided by the facility dated April 15, 2021, through November 3, 2021, errantly indicated a room number for Resident 84 in which he did not reside when compared to the above census information.
A Bed Side Rail and Mattress audit sheet used to evaluate zones of entrapment dated May 4, 2021, and October 29, 2021, assessed Zone 4 as not applicable.
Resident 84's clinical record contained no evidence of an assessment of his bed enabler devices during the year 2022.
A Bed Safety with Measuring Tool assessment dated [DATE], completed by the registered nurse, indicated that the devices passed all zones; however, included no actual measurements.
Interview with the Nursing Home Administrator and the Director of Nursing on January 26, 2023, at 1:30 PM confirmed that the facility could not provide quarterly assessments of Resident 84's enabler devices as per the facility policy. The interview indicated that maintenance staff assess the measurements of the entrapment zones when installing devices on beds and refer these measurements to nursing staff who complete the electronic assessments. The facility was unable to provide a complete assessment (to include Zone 4) for Resident 84 from which the registered nurse could accurately document that all zones passed the risk assessment. The surveyor also reviewed that the available electronic assessments reflect a room number in which Resident 84 did not reside at the time of the assessments.
Interview with the Director of Nursing on January 27, 2023, at 10:15 AM confirmed that the facility had no additional information for Resident 84.
Interview with Employee 11 (maintenance director) on January 27, 2023, at 10:45 AM confirmed that, at a minimum, each resident assessment for enabler bar use should include Zones one through four; however, there was no evidence of this for Residents 55 and 84. The entry of N/A or not applicable, was not an appropriate assessment for Zone four.
28 Pa. Code 211.10(d) Resident care policies
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
- "What safeguards are in place to prevent abuse and neglect?"
- "Why is there high staff turnover? How do you retain staff?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Pennsylvania facilities.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s). Review inspection reports carefully.
- • 55 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade F (15/100). Below average facility with significant concerns.
- • 68% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
✓ Report will be sent to your email
About This Facility
What is Bradford Hills Nursing & Rehabilitation Center's CMS Rating?
CMS assigns BRADFORD HILLS NURSING & REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Bradford Hills Nursing & Rehabilitation Center Staffed?
CMS rates BRADFORD HILLS NURSING & REHABILITATION CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 68%, which is 22 percentage points above the Pennsylvania average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Bradford Hills Nursing & Rehabilitation Center?
State health inspectors documented 55 deficiencies at BRADFORD HILLS NURSING & REHABILITATION CENTER during 2023 to 2025. These included: 1 that caused actual resident harm, 53 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Bradford Hills Nursing & Rehabilitation Center?
BRADFORD HILLS NURSING & 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 ALLAIRE HEALTH SERVICES, a chain that manages multiple nursing homes. With 200 certified beds and approximately 145 residents (about 72% occupancy), it is a large facility located in TROY, Pennsylvania.
How Does Bradford Hills Nursing & Rehabilitation Center Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, BRADFORD HILLS NURSING & REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (68%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.
What Should Families Ask When Visiting Bradford Hills Nursing & Rehabilitation Center?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the substantiated abuse finding on record and the facility's high staff turnover rate.
Is Bradford Hills Nursing & Rehabilitation Center Safe?
Based on CMS inspection data, BRADFORD HILLS NURSING & REHABILITATION CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Pennsylvania. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Bradford Hills Nursing & Rehabilitation Center Stick Around?
Staff turnover at BRADFORD HILLS NURSING & REHABILITATION CENTER is high. At 68%, the facility is 22 percentage points above the Pennsylvania average of 46%. Registered Nurse turnover is particularly concerning at 67%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was Bradford Hills Nursing & Rehabilitation Center Ever Fined?
BRADFORD HILLS NURSING & REHABILITATION CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Bradford Hills Nursing & Rehabilitation Center on Any Federal Watch List?
BRADFORD HILLS NURSING & 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.