RIVER VIEW NURSING AND REHABILITATION CENTER
For profit - Corporation
180 Beds
IMPERIAL HEALTHCARE GROUP
Data: November 2025
Trust Grade
20/100
#625 of 653 in PA
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
River View Nursing and Rehabilitation Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. With a state ranking of #625 out of 653, they are in the bottom half of Pennsylvania facilities, and #22 out of 22 in Luzerne County, meaning there are no better local options available. However, the facility has shown some improvement, decreasing from 20 issues in 2024 to 13 in 2025. Staffing is rated average with a 3/5 star rating, but the 57% turnover is concerning, as it is higher than the state average of 46%. While there have been no fines, which is a positive aspect, the facility has faced serious issues, including failing to implement proper infection control measures, which placed multiple residents at risk for COVID-19, and not providing necessary adaptive dining equipment for residents with swallowing difficulties.
- Trust Score
- F
- In Pennsylvania
- #625/653
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 57% 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 ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for Pennsylvania. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 78 deficiencies on record. Higher than average. Multiple issues found across inspections.
20/100
Bottom 5%
Review needed
20 → 13 violations
★☆☆☆☆
1.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★☆☆☆☆
1.0
Inspection Score
↔
Stable
2024: 20 issues
2025: 13 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: 57%
11pts above Pennsylvania avg (46%)
Frequent staff changes - ask about care continuity
Chain: IMPERIAL HEALTHCARE GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (57%)
9 points above Pennsylvania average of 48%
The Ugly 78 deficiencies on record
Sept 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 F0810
(Tag F0810)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interviews, it was determined the facility failed to provide adaptive di...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation, and staff interviews, it was determined the facility failed to provide adaptive dining equipment as required and prescribed for three residents out of 12 sampled (Residents 1, 2, and 3).Findings include: A review of the clinical record revealed Resident 1 was admitted to the facility on [DATE], with diagnosis to include dysphagia (difficulty swallowing food or liquid), mild protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health), and lack of coordination. A review of the physician's orders, dated January 16, 2025, revealed the resident was to utilize a Kennedy cup (lightweight, spill-proof drinking cup designed to be easy to hold and grip) with meals. Review of Resident 1's plan of care, dated June 7, 2024, indicated the resident had a nutritional problem or potential nutritional problem due to variable appetite, history of protein-calorie malnutrition and dysphagia. Interventions included the use of adaptive equipment. More specifically, the resident was to utilize a Kennedy cup with all hot beverages. Observation of Resident 1's lunch meal ticket (a menu-based document that provides essential information about a resident ' s meal such as diet order, preferences, food allergies, dislikes, dining location, supplements, and adaptive equipment if required, and helps staff accurately prepare and serve meals to residents based on their individual needs and preferences) indicated the resident was to be provided with a Kennedy cup. However, an observation of the lunch meal tray on September 23, 2025, at 11:43 AM, revealed that the dietary staff failed to provide the physician-ordered Kennedy cup to the resident.A review of the clinical record revealed Resident 2 was admitted to the facility on [DATE], with diagnosis to include muscle wasting and atrophy (a condition that causes a progressive loss of muscle mass, strength, function, and power), and major depressive disorder. A review of the physician's orders dated April 27, 2023, revealed the resident was to utilize a Kennedy cup with all meals. Review of Resident 2's plan of care, dated January 21, 2025, indicated the resident had a nutritional problem or potential nutritional problem due to muscle wasting and atrophy, COPD (chronic obstructive pulmonary disease- type of obstructive lung disease which causes difficulty breathing), type 2 diabetes (a chronic disease where the body does not use insulin properly, leading to high blood sugar levels) , metabolic encephalopathy( temporary brain dysfunction caused by chemical imbalances in the body, such as infection, organ failure, or electrolyte problems), dysphagia, sepsis (a life-threatening condition where the body's response to an infection spreads through the bloodstream and can cause organ failure), hypokalemia (low levels of potassium, a mineral important for heart and muscle function, in the blood), iron deficiency anemia (a condition where a lack of iron leads to too few healthy red blood cells, causing fatigue and weakness), osteoarthritis (a common joint disease where the cartilage wears down, leading to pain, stiffness, and limited movement), hypertension (high blood pressure), GERD (Gastroesophageal Reflux Disease- a condition where stomach acid flows back into the esophagus, causing heartburn and irritation.), depression, altered skin integrity, and significant weight gain. Interventions included the use of adaptive equipment. More specifically, the resident was to utilize a Kennedy cup.Observation of Resident 2's lunch meal ticket indicated the resident was to be provided with a Kennedy cup. However, an observation of the lunch meal tray on September 23, 2025, at 11:45AM, revealed the dietary staff failed to provide the physician-ordered Kennedy cup to the resident.A review of the clinical record revealed Resident 3 was admitted to the facility on [DATE], with diagnosis to include dysphagia, severe protein-calorie malnutrition, legal blindness, and lack of coordination. A review of the physician's orders dated July 30, 2025, revealed the resident was to utilize a Kennedy cup for all liquids. Review of Resident 3's plan of care dated July 17, 2026, indicated the resident had a nutritional problem or potential nutrition problem due to malnutrition. Interventions failed to include the use of the physician ordered Kennedy cup for all meals. Observation of the lunch meal tray on September 23, 2025, at 11:47 AM, revealed the dietary staff failed to provide the physician-ordered Kennedy cup to the resident.An interview with Employee 1 (nurse aide) on September 23, 2025, at 11:50 AM, stated the dietary staff frequently fail to provide Kennedy cups on the resident trays. She further stated that nursing staff must then stop meal service to contact the kitchen to obtain the adaptive equipment, causing interruptions in resident care and meal service.Interview with the Dietary Manager on September 23, 2025, at approximately 2:50 PM, confirmed the facility failed to consistently provide the required adaptive dining equipment as ordered by the physician. 28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Jun 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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on a review of clinical records, controlled drug records, and staff interviews, it was determined the facility failed to implement procedures to promote accurate accounting and the administratio...
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Based on a review of clinical records, controlled drug records, and staff interviews, it was determined the facility failed to implement procedures to promote accurate accounting and the administration of controlled medications for one of 14 residents sampled (Resident 1).
Findings include:
A review of a facility policy titled Administering Medications, last reviewed on January 22, 2025, revealed that medications are administered in accordance with prescriber orders, including any required time frame, and are administered within one hour of their prescribed time unless otherwise specified. As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered.
A review of Resident 1's clinical record revealed a physician's order dated March 21, 2025, for Oxycodone 10 mg (an opioid pain medication used to treat moderate to severe pain), with instructions to administer one tablet three times a day for back pain.
A review of the controlled substance record for Resident 1's Oxycodone 10 mg tablet (schedule II opiate narcotic medication; schedule II drugs have a high potential for abuse) showed that nursing staff signed out doses of the medication on the following dates and times:
May 3, 2025, at 6:00 AM
May 24, 2025, at 6:00 AM.
However, a review of Resident 1's May 2025 Medication Administration Record (MAR) revealed there was no documentation indicating that the medication was administered to the resident on these dates and times.
During an interview on June 18, 2025, at 2:30 PM, the Nursing Home Administrator confirmed the discrepancies in the accounting and administration of opioid pain medications for Resident 1.
28 Pa Code 211.5 (f)(xi) Medical records
28 Pa Code 211.12 (d)(1)(3)(5) Nursing services
28 Pa Code 211.9(a)(1)(k) Pharmacy 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews, it was determined the facility failed to provide nursing services co...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interviews, it was determined the facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses administered medications as prescribed to three residents out of 14 sampled (Resident 1, 2, and CR1).
Findings included:
According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.11 (a)(1)(2)(4) indicates that the Registered Nurse (RN) was to collect complete ongoing data to determine nursing care needs, analyze the health status of individuals and compare the data with the norm when determining nursing care needs, and carry out nursing care actions that promote, maintain, and restore the well-being of individuals.
The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health care team by exercising sound judgment based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) document and maintain accurate records.
A review of a facility policy titled Administering Medications, last reviewed on January 22, 2025, revealed that medications are administered in accordance with prescriber orders, including any required time frame, and are administered within one hour of their prescribed time unless otherwise specified. As required or indicated for a medication, the individual administering the medication records in the resident's medical record the date and time the medication was administered.
A clinical records review revealed Resident 1 was admitted to the facility on [DATE], with diagnoses of dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and bipolar disorder (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration).
A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 19, 2025, revealed Resident 1 had moderately impaired cognition with a BIMS score of 10 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired).
A review of Resident 1's clinical record revealed a physician's order dated March 21, 2025, for Oxycodone 10 mg (an opioid pain medication used to treat moderate to severe pain), with instructions to administer one tablet three times a day for back pain.
A review of Resident 1's May 2025 Medication Administration Record (MAR) revealed the resident did not receive their scheduled oxycodone 10 mg administration on May 8, 2025, at 2:00 P.M.
An interview with Resident 1 on June 18, 2025, at 1:00 P.M. revealed he did not receive his medication on May 8, 2025, at 2:00 P.M., and stated they did not give a reason why it wasn't administered.
A clinical records review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses to include neuropathy (a nerve problem that can cause pain, numbness, tingling, swelling, or muscle weakness in different parts of the body) and depression (a mental health condition characterized by low mood or loss of pleasure or interest in activities for long periods of time).
A review of a quarterly MDS dated [DATE], revealed Resident 2 had moderately impaired cognition with a BIMS score of 11 (a score of 8-12 indicates cognition is moderately impaired).
A review of Resident 2's clinical record revealed a physician's order dated January 2, 2025, for Gabapentin 100 mg (a medication used to treat neuropathic pain), with instructions to give two capsules three times a day for neuropathy.
A review of Resident 2's May 2025 MAR revealed the resident did not receive their scheduled gabapentin 100 mg administration on May 8, 2025, at 2:00 P.M.
A clinical records review revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses to include chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and fracture (a bone break) of the acetabulum (part of the pelvis that forms the socket of the hip joint, where the head of the thigh bone fits in).
A review of a quarterly MDS dated [DATE], revealed that Resident CR1 was cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact).
A review of Resident CR1's clinical record revealed a physician's order dated April 9, 2025, for Gabapentin 600 mg, with instructions to give one capsule three times a day for neuropathy.
A review of Resident CR1's May 2025 MAR revealed the resident did not receive the scheduled gabapentin 100 mg administration on May 8, 2025, at 2:00 P.M.
A review of a medication error report, dated May 9, 2025, for Resident 1 revealed he did not receive his medication at 2:00 P.M. Further review revealed the nurse assigned to his unit left early, and she did not give Resident 1 his scheduled oxycodone for 2:00 P.M.
A review of a facility investigative report/employee corrective action form, dated May 13, 2025, revealed Employee 1, LPN, had accepted the assignment from Employee 2, LPN, without ensuring that all care and medications ordered were provided before the end of the shift. Further review revealed that Employee 2 left the assigned unit for an extended period of time without ensuring alternative coverage of the assignment was available.
An interview with Employee 1 on June 18, 2025, at approximately 1:30 P.M. revealed she did take over Employee 2's assignment on May 8, 2025, around 1:00 P.M., due to Employee 2 having to leave early. Employee 1 stated prior to her taking over the assignment, she had been an extra staff member in the facility throughout the day and was assisting other employees who needed help. Employee 1 stated after she received the report, she had left the unit she was then assigned to help assist employees on another floor. Employee 1 stated she was not sure how long exactly she left the floor but stated it was not a long time, around five minutes. Employee 1 did acknowledge she did not check to make sure resident medications and treatments were provided before she left her shift at 3:00 P.M. When asked if she knew what treatments or medications were not provided before the end of the shift, she stated that three residents had missed their 2:00 P.M. medication administration, which had consisted of an oxycodone and two gabapentin doses.
An interview with Employee 2 on June 18, 2025, at approximately 1:00 P.M., revealed she was assigned to Resident 1 on May 8, 2025, for the 7:00 A.M. to 3:00 P.M. shift and left early due to a family emergency and gave report to Employee 1, who took over the assignment until the end of the shift. Employee 2 stated after she gave report, she saw Employee 1 go in the elevator and leave the unit.
There were no medication error reports for Resident 2 and Resident CR1 available for review.
An interview with the Nursing Home Administrator on June 18, 2025, at approximately 2:30 P.M., confirmed the nurse failed to administer medications as prescribed,
The facility failed to provide nursing services consistent with professional standards of quality to ensure that licensed nurses administered medications as prescribed to Resident 1, Resident 2, and CR1.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services
28 Pa. Code 211.5 (f) (xi) Medical Records
Apr 2025
10 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to accurately identify a resident's re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined the facility failed to accurately identify a resident's request for future health care and advance directives (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) as evidenced by one resident (Resident 173) out of 27 residents sampled.
Findings include:
A review of the clinical record of Resident 173, revealed the resident was admitted to the facility on [DATE], with diagnoses that included osteoarthritis (type of arthritis that causes joints to become painful and stiff) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow).
Review of Resident 173's clinical record revealed a completed and signed POLST (Physician Orders for Life-Sustaining Treatment a medical order form used to communicate a resident's preferences for life-sustaining measures across care settings) dated [DATE]. The POLST indicated that the resident elected DNR status (Do Not Resuscitate a medical order directing that cardiopulmonary resuscitation [CPR], a life-saving procedure performed when the heart or breathing stops, should not be attempted), with a goal of allowing a natural death.
Further review of the resident's current physician orders, initially entered on [DATE], in the electronic health record, identified the resident's code status as Full Code, indicating CPR was to be performed in the event of cardiopulmonary arrest.
There was no documentation to indicate that Resident 173 had revised the advance directive or changed the preference documented on the POLST. No clinical notes or care conference records reflected a discussion or update to the resident's wishes regarding life-sustaining treatment.
An interview with the Director of Nursing (DON) on [DATE], at 9:10 AM confirmed that physician orders are required to align with the most current, signed POLST. The DON acknowledged that Resident 173 had elected DNR status on the POLST form and the current physician orders incorrectly reflected Full Code, which did not honor the resident's documented treatment preferences.
28 Pa. Code 201.29(a) Resident rights.
28 Pa. Code 211.5 (f)(i) Medical records.
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of facility policy, investigative documentation, and staff and resident int...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of facility policy, investigative documentation, and staff and resident interviews, it was determined the facility failed to thoroughly investigate an incident involving a fall with minor injury to determine whether neglect occurred and failed to identify that planned fall interventions were not in place for one of 27 sampled residents (Resident 57).
The findings include:
A review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that residents have the right to be free from abuse and neglect. The policy indicated the facility's resident abuse and neglect prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: (1) protect residents from abuse and neglect by anyone, including, but not necessarily limited to, facility staff and other residents.
Further review of the facility policy revealed the facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property, and will investigate and report any allegations within time frames required by federal requirements.
A review of Resident 57's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) dependent on dialysis (the process of removing waste products and excess fluid from the body when the kidneys are unable to adequately filter the blood) and bilateral below-the-knee amputation of the lower extremities.
A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated December 12, 2024, revealed that Resident 57 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired).
Additionally, the MDS indicated the resident had functional limitations in range of motion with impairments to both sides of the lower extremities, and the resident was indicated to be dependent with bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair).
The most current review of a quarterly MDS, dated [DATE], revealed that Resident 57 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact).
Resident 57's comprehensive person-centered plan of care initiated on November 23, 2024, indicated the resident required the assistance of two staff members with transfers. The care plan was revised on December 16, 2024, to include the use of a mechanical lift (a mechanical device designed to lift/transfer individuals that have limited mobility in a safe manner and reduce injuries) with transfers.
A review of Resident 57's clinical record revealed physician's orders dated December 6, 2024, to utilize a mechanical lift for all transfers and bed mobility with the assistance of two staff members.
A review of Resident 57's task report (an electronic record that summarized planned resident-centered tasks completed by nursing) initiated on December 8, 2024, revealed that Resident 57 was an assist of two staff members via the mechanical lift for transferring.
A review of a facility investigative report dated December 13, 2024, at approximately 2:30 PM, revealed that Employee 14, an agency nurse aide, was transferring Resident 57 and experienced a fall during the transfer.
A review of a facility investigative report dated December 13, 2024, at approximately 2:30 PM, revealed that Employee 14, an agency nurse aide was transferring Resident 57 and experienced a fall during the transfer.
A review of a witness statement from Employee 14, dated 2:30 PM, indicated he was transferring the resident to his wheelchair and grabbed the resident under both arms, and that Resident 57 was holding onto him with both arms and while during the transfer his left below-the-knee amputation stump became stuck in the wheelchair arm. Employee 14 then called out for help and received assistance from Employee 15, the maintenance director, to help dislodge his stump from the wheelchair arm. Employee 14 then attempted to reposition the resident into the wheelchair but stumbled over clutter on the floor and placed the resident on the floor to prevent harm. The statement did not acknowledge that the mechanical lift, as required by physician order and care plan, had not been used.
A review of a witness statement from Employee 15, dated 2:30 PM, indicated that he heard someone yelling for help and witnessed Employee 14 holding Resident 57 under both arms while Resident 57 had both of his arms wrapped around Employee 14, and Employee 14 asked Employee 15 to help dislodge his left stump from the wheelchair arm. Employee 15 assisted in freeing the resident's stump from the wheelchair arm. After the stump was freed, Employee 14 lost balance and the resident was found lying on the floor. Employee 15 also observed clutter on the floor and water from a bottle that spilled during the incident.
A review of a nurse's incident/accident statement dated December 13, 2024, at 4:21 PM, revealed that they found Resident 57 on the floor lying next to Employee 14 and noted debris of a cup, paper, and water on the floor.
The facility investigation failed to obtain a resident statement from Resident 57 at the time of the incident. During the survey, the Nursing Home Administrator (NHA) was unable to explain the omission of the resident's statement. When interviewed on April 24, 2025, at 8:40 AM, Resident 57 stated that he had informed Employee 14 he required a mechanical lift with two-person assistance, but the aide proceeded to transfer him manually. The resident believed the aide
in a hurry to get the transfer done faster.
A nurse's progress note dated December 14, 2024, at 10:37 AM documented complaints of rib pain, and a subsequent x-ray was ordered. Although the December 17, 2024, radiology report showed no fracture, a physician's note dated December 19, 2024, noted that Resident 57 was likely to have a right rib contusion (bruise), as x-ray findings were negative, and the resident was experiencing pain.
The resident required Tylenol for rib pain on multiple occasions between December 14-20, 2024, with reported pain scores ranging from 3 to 8 (pain scale of 1 to 10 1 being no pain and 10 being the worst pain).
The facility investigation lacked evidence the facility evaluated whether the plan of care for Resident 57 was implemented as directed. There was no documentation identifying the resident was transferred by only one staff member or that the mechanical lift was not used. The facility failed to identify or document the deviation from the care plan.
Furthermore, attempts to re-contact Employee 14 during the on-site survey were unsuccessful. The NHA was unable to provide documentation or rationale for the staff member's departure from the facility. Employee 15, interviewed on April 24, 2025, stated he did not know why the aide was transferring the resident alone.
A review of Employee 14 personnel file acknowledged that he completed training and was deemed proficient to perform all assigned tasks, including proper transfer techniques, and received training on abuse and neglect of a resident.
Despite this documented training and acknowledgment of competency, review of Resident 57's clinical record confirmed that Employee 14 failed to adhere to established protocols by not using the required mechanical lift to transfer Resident 57 along with another staff member on December 13, 2024.
The facility failed to implement its established procedures in response to a fall with minor injury by failing to conduct a thorough investigation to rule out potential abuse, neglect, or mistreatment of the resident as a potential cause of the fall with minor injury. There was no indication the facility identified at the time of the incident that there was only one nurse aide, Employee 14, and no use of a mechanical lift for transfers.
During an interview conducted on April 24, 2025, at 1:30 PM, the NHA confirmed that the facility could not provide documented evidence the facility fully investigated to rule out potential neglect following Resident 10's fall with minor injury. The facility failed to identify that planned interventions were not in place and/or implemented in a manner to ensure the resident's safety to prevent the fall and prevent future reoccurrence to the extent possible and implement appropriate corrective actions to prevent recurrence.
Refer F600
28 Pa. Code 201.14 (a)(c) Responsibility of licensee
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29 (a)(c) Resident Rights
28 Pa. Code 211.12 (c)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 a review of clinical records and the Resident Assessment Instrument (RAI) and staff interviews, it was determined the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the Resident Assessment Instrument (RAI) and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of three residents out of 27 sampled (Residents 2, 40, and 47).
Findings included:
A review of Resident 2's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and atrial fibrillation (an irregular heart rate that commonly causes poor blood flow).
A current physician order initially dated January 28, 2025, noted an order for Warfarin Sodium (an anticoagulant medication also known as a blood thinner) 4 mg via PEG-tube (percutaneous endoscopic gastrostomy- feeding tube placed directly into the stomach through the abdominal wall to provide liquid nutrition, medications, and fluids into the stomach) at bedtime for diagnosis of atrial fibrillation.
A review of Resident 2's February 2025 Medication Administration Record revealed Apixaban 5 mg (anticoagulant) was administered daily as ordered by the physician.
A review of Resident 2's quarterly MDS assessment dated [DATE], indicated the resident did not receive an anticoagulant (blood thinner) medication during the 7-day look-back period.
An interview with the RNAC (registered nurse assessment coordinator) on April 23, 2025, at approximately 1:30 PM confirmed Resident 2's MDS assessment was not accurate.
A review of Resident 40's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).
A review of Resident 40's annual MDS assessment dated [DATE], Section I active diagnoses, infection in the past seven days, indicated infections of MDRO (multi-drug resistant organism is a germ that is resistant to many antibiotics) and pneumonia (infection that affects one or both lungs, which makes it difficult to breathe and can cause a fever and cough). However, review of the clinical record revealed no documented evidence the resident had an MDRO infection or pneumonia.
An interview with the RNAC on April 23, 2025, at approximately 1:45 PM confirmed that Resident 40 did not have an MDRO infection or pneumonia during the seven-day look-back period of the MDS assessment. The RNAC confirmed that Resident 40's MDS assessment was not accurate.
A clinical record review revealed Resident 47 was admitted to the facility on [DATE], with diagnoses to include diabetes (a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces).
A review of a 5-day MDS assessment dated [DATE], Section N0350. Insulin: Resident 47 did not receive any insulin injections during the seven-day look-back period. However, a review of Resident 47's Medication Administration Record dated February 2025 revealed Resident 47 received a Lantus 100 unit/ml solution pen injector (insulin) on five occasions from February 7, 2025, through February 11, 2025.
During an interview on April 24, 2025, at approximately 1:30 PM, the RNAC confirmed Resident 47's February 11, 2025, MDS, Section N0350. Insulin was not accurate.
28 Pa. Code 201.18(e)(1) Management
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 F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interview, it was determined the facility failed to ensure th...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility policy review, and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of intravenous medication via a peripheral IV (thin, flexible plastic tube inserted into a peripheral vein to allow for the administration of fluids, medications, and other therapies into the bloodstream and used for short-term intravenous therapy) for one of 27 residents reviewed (Resident 101).
Findings include:
According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following:
The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice.
Chapter 21.145b. IV therapy curriculum requirements;
(f) An LPN may perform only the IV therapy functions for which the LPN
possesses the knowledge, skill and ability to perform in a safe manner, except as
limited under § 21.145a (relating to prohibited acts), and only under supervision
as required under paragraph (1).
(1) An LPN may initiate and maintain IV therapy only under the direction
and supervision of a licensed professional nurse or health care provider authorized
to issue orders for medical therapeutic or corrective measures (such as a
CRNP, physician, physician assistant, podiatrist or dentist).
(g) An LPN who has met the education and training requirements of § 21.145b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under § 21.145a and only under supervision as required under subsection (f):
(1) Adjustment of the flow rate on IV infusions.
(2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions.
(3) Administration of IV fluids and medications.
(4) Observation of the IV insertion site and performance of insertion site care.
(5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes.
(6) Discontinuance of a medication or fluid infusion, including infusion devices.
(7) Conversion of a continuous infusion to an intermittent infusion.
(8) Insertion or removal of a peripheral short catheter.
(9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders.
(10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route.
(11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system.
(12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions.
(13) Collection of blood specimens from an IV access device.
A review of the facility Continuous Administration of IV Fluids by Pump Policy dated January 22, 2025, indicated that continuous infusions of IV fluids or medications in volumes greater than 250 ml may be controlled via electronic pump. Further review of the policy failed to include which licensed nursing staff (RN or LPN) would be responsible for the infusion of physician ordered IV fluids or medications.
Interview with the administrator (NHA) and director of nursing (DON) on April 24, 2025, at approximately 10:00 AM confirmed the facility did not have a written policy or protocols to allow LPNs to administer IV fluids or medications. The NHA and DON failed to provide written evidence that LPNs employed at the facility had completed a Board approved educational program to start and discontinue an intravenous infusion and administer and withdraw intravenous fluids and medications with a physician's order. The NHA and DON also failed to provide documented evidence that a yearly in-service on administration of IV fluids and medications was provided to LPNs who have completed the Board certified educational program.
Clinical record review revealed that Resident 101 was admitted to the facility on [DATE], with diagnoses which included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).
A physician order dated April 16, 2025, noted an order for Meropenem-Sodium Chloride Intravenous Solution (an antibiotic) reconstituted 500 MG/50ML use 500MG intravenously every 8 hours for urinary tract infection for seven days.
An IV therapy note dated April 16, 2025, noted that a peripheral IV was placed in the right forearm.
Review of the Resident 101's April 2025 Medication Administration Record (MAR) revealed that between April 16 through April 22, 2025, Employee 1 (LPN), Employee 2 (LPN), Employee 3 (LPN), Employee 4 (LPN), and Employee 5 (LPN) signed the MAR as administering the IV antibiotic medication to the resident through the peripheral IV.
Interview on April 24, 2025, at approximately 11:00 AM with Employee 1 (LPN), stated she never administered medications through residents' intravenous lines at the facility based on facility policy. She confirmed that she did sign out on April 16, 2025, at 2:00 PM that she had administered the medication even though the RN was the one who had administered the IV medication through the resident's peripheral IV. Employee 1 (LPN) indicated she was never educated at the facility on the administration of intravenous medications.
There was no documented evidence of any education or supervision regarding IV administration for any LPNs working at the facility.
During an interview on April 25, 2025, at approximately 9:00 AM the DON failed to provide documented evidence that LPNs in the facility received education regarding the administration of intravenous medications. The DON further confirmed that facility policy indicated the nurse administering the medications are to sign the MAR indicating it was administered.
28 Pa. Code 201.20(a) Staff Development.
28 Pa Code 211.12 (d)(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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, resident, and staff interviews, it was determined the facility failed to develop and impl...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, resident, and staff interviews, it was determined the facility failed to develop and implement an individualized person-centered plan to render trauma informed care to a resident with a diagnosis of Post-Traumatic Stress Disorder for one out of 27 residents reviewed (Resident 55).
Findings include:
A review of Resident 55's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included Post Traumatic Stress Disorder (PTSD a mental health condition that's caused by an extremely stressful or terrifying event, either being part of it or witnessing it. Symptoms may include flashbacks, nightmares, severe anxiety, and uncontrollable thoughts about the event).
A review of the clinical record also revealed a physician's order dated March 12, 2025, for Prazosin HCL (a medication that decreases levels of norepinephrine in the central nervous system thereby reducing nightmares related to PTSD), with instructions to administer 1 mg tablet by mouth at bedtime for nightmares.
During an interview conducted on April 23, 2025, at approximately 12:45 PM, Resident 55 indicated he served two tours in Vietnam and had nightmares every night prior to the initiation of the Prazosin.
The resident's current care plan, in effect at the time of review on April 25, 2025, did not identify the resident's PTSD symptoms or triggers related to this diagnosis and resident specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization.
The facility failed to develop and implement an individualized person-centered plan to address, this resident's diagnosis of PTSD according to standards of practice to promote the resident's emotional well-being and safety.
Interview with the Nursing Home Administrator and Director of Nursing on April 25, 2025, at 8:50 AM, confirmed the facility was unable to demonstrate the facility provided culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.
28 Pa Code 211.12 (d)(3)(5) Nursing services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to en...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy, and staff interviews, it was determined the facility failed to ensure that a resident's drug regimen was free of unnecessary antibiotics for one out of 27 residents sampled (Resident 47).
Findings included:
A review of the facility policy titled Antibiotic Stewardship, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. The policy indicates when a resident is admitted from an emergency department, the admitting nurse will review discharge and transfer paperwork for current antibiotic and anti-infective orders. When a culture and sensitivity (C&S) is ordered, lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.
A clinical record review revealed Resident 47 was admitted to the facility on [DATE], with diagnoses that include epilepsy (a chronic brain disorder in which groups of nerve cells, or neurons, in the brain sometimes send the wrong signals and cause seizures).
A progress note dated March 24, 2025, at 2:06 PM revealed Resident 47 was sent to the community emergency department related to lethargy and a change in mental status.
A progress note dated March 24, 2025, at 10:49 PM, indicated that Resident 47 returned to the facility from a community emergency department visit. The note documented the physician to verify new medications from the hospital, including Cephalexin 500 mg (an antibiotic medication), and instructed that all hospital-prescribed medications be continued. The note further indicated that the physician planned to evaluate the resident in person the following day. Resident 47's vital signs at the time were assessed to be within normal limits.
A physician's order initiated on March 25, 2025, at 10:30 PM directed administration of Cephalexin oral capsule 500 mg by mouth four times daily for a urinary tract infection (UTI), with a stop date of April 1, 2025.
Laboratory review revealed a urine culture (method to grow and identify bacteria that may be in the urine) and quantitative report dated March 26, 2025, at 7:35 AM. The results showed no significant growth, indicating the absence of detectable bacteria or other microorganisms in the urine. A concurrent urinalysis noted an elevated white blood cell (WBC) count at 30-49 per high-powered field (normal range: 0-2/HPF), but no clinical documentation correlated this laboratory result with active symptoms of a urinary tract infection.
A review of the Medication Administration Record (MAR) for March 2025 revealed that Resident 47 was administered a total of 25 doses of Cephalexin 500 mg from March 24, 2025, through April 1, 2025.
A comprehensive review of the clinical record failed to reveal documentation of any clinical signs or symptoms of a UTI from March 24, 2025, through April 1, 2025, including but not limited to, acute dysuria (painful urination), elevated temperature, increased urinary urgency, suprapubic pain, increased urinary incontinence, or gross hematuria.
During an interview on April 24, 2025, at approximately 1:30 PM, the facility's Infection Preventionist (IP) confirmed that the clinical record did not contain documentation of a clinical rationale supporting the continued use of Cephalexin for Resident 47 during the noted period.
In an interview conducted on April 25, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) was unable to provide documentation of a clinical rationale for the administration of Cephalexin oral capsule 500 mg. The NHA acknowledged it is the facility's responsibility to ensure that each resident's drug regimen remains free from unnecessary antibiotics.
28 Pa. Code 211.2(d)(3)(5) Medical Director
28 Pa. Code 211.12(d)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, it was determined that the facility failed to show adequate m...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, it was determined that the facility failed to show adequate monitoring of symptoms and potential adverse consequences of psychoactive drug use for one resident out of 27 residents sampled (Resident 45).
Findings include:
A review of clinical records revealed Resident 45 was admitted to the facility on [DATE], with diagnoses to include schizoaffective disorder (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), bipolar type (a mental health disorder that causes unusual shifts in a person's mood, energy, activity levels, and concentration), and Parkinson's (progressive neurological disorder that affects movement) without dyskinesia (involuntary movement disorder characterized by uncontrolled and jerky movements).
A review of a facility policy titled Psychotropic Medication Use, last reviewed by the facility on January 22, 2025, revealed that psychotropic medication is any medication that affects brain activity associated with mental processes and behavior, and medications in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: antipsychotics, antidepressants, anti-anxiety medications and hypnotics/sedatives. Further review of the policy revealed that residents receiving psychotropic medications are monitored and the response to the treatment is documented. In addition, residents are monitored for adverse consequences associated with psychotropic medications, including neurologic effects such as extrapyramidal symptoms (tremors, disturbed gait, increased agitation, restlessness, involuntary movement of mouth or tongue), parkinsonism, and tardive dyskinesia (repetitive involuntary movements caused by long-term use of antipsychotics).
A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 7, 2025, revealed that Resident 45 had moderately impaired cognition with a BIMS score of 12 (Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 8-12 indicates cognition is moderately impaired).
A review of Resident 45's comprehensive person-centered care plan, initiated on August 22, 2024, identified the resident's use of psychotropic medications. The care plan included an intervention to monitor, document, and report adverse reactions to psychotropic medications, including but not limited to unsteady gait, tardive dyskinesia (a condition characterized by involuntary, repetitive body movements, often affecting the face), and extrapyramidal symptoms (drug-induced movement disorders such as tremors or muscle rigidity). The care plan did not reflect that Resident 45 was experiencing any current symptoms or adverse effects related to the use of psychotropic medications.
A review of the resident's clinical record revealed active physician's orders for the following prescribed psychotropic medications:
Invega (paliperidone) 6 mg by mouth daily for schizoaffective bipolar disorder (a psychotic disorder characterized by symptoms of schizophrenia and mood disturbances).
Depakote (divalproex sodium) 125 mg, four capsules three times daily for schizoaffective bipolar disorder (a mood stabilizer used to treat seizures, bipolar disorder, and prevent migraine headaches).
Lexapro (escitalopram) 10 mg, one tablet daily for depression (a selective serotonin reuptake inhibitor [SSRI], a type of antidepressant).
Ativan (lorazepam) 0.5 mg every 12 hours as needed for anxiety or agitation (a benzodiazepine that acts as a sedative and anti-anxiety agent).
During an interview with Resident 45 on April 22, 2025, at 11:30 AM, the resident was observed to have slurred speech, involuntary limb movements, tremors, and lip-smacking behavior, symptoms commonly associated with adverse reactions to psychotropic medications.
A review of an outside consultant psychiatry progress note dated April 22, 2025, documented that Resident 45 exhibited tremors on the psychomotor examination. However, a review of the resident's physician's orders and Medication Administration Record (MAR) for April 2025 did not reflect any orders or documentation related to the monitoring of side effects or adverse consequences of antipsychotic medications.
The facility was unable to provide evidence the resident's observed symptoms or potential adverse effects of psychotropic medications were being monitored or addressed in the clinical record, nor were the symptoms reflected or updated in the resident's care plan.
Following surveyor inquiry, a physician's order dated April 24, 2025, was issued to monitor Resident 45 for side effects of antipsychotic medications, including confusion, lethargy, tremors, disturbed gait, increased agitation, restlessness, and involuntary movement of the mouth or tongue.
An interview conducted with the Director of Nursing on April 25, 2025, at approximately 1:30 PM confirmed the facility had not been monitoring or documenting Resident 45's current symptoms or potential adverse consequences of psychotropic medication use prior to April 24, 2025.
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policies, documentation provided by the facility, and staff interviews, i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policies, documentation provided by the facility, and staff interviews, it was determined the facility failed to ensure that four residents out of 27 sampled (Residents 18, 104, 108, and 224) were free from abuse perpetrated by another resident (Residents 37 and 49) and failed to ensure one resident out of 27 sampled was free from neglect (Resident 57).
Findings include:
A review of the facility policy titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy that residents have the right to be free from abuse and neglect. The policy indicated the facility's resident abuse and neglect prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: (1) protect residents from abuse and neglect by anyone, including, but not necessarily limited to, facility staff and other residents.
A clinical record review revealed Resident 49 was admitted to the facility on [DATE], with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning, such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities).
A review of a five-day Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 31, 2025, Section C1000. Cognitive Skills for Daily Decision Making revealed that Resident 49 is severely impaired in her ability to make decisions regarding tasks of daily life. The assessment indicated the resident's BIMS score was 99 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 99 indicates that the resident was unable to provide or did not provide answers to complete this section).
A care plan revealed Resident 49 is at risk for harm related to homicidal ideation, grabbing other residents, and resident-to-resident altercations initiated on April 15, 2024. Interventions in place to assist Resident 49 with her goal of other residents remaining without injury include a one-staff-to-one-resident level of observation, one-staff-to-one-resident re-education including maintaining distance from other residents, keeping the resident at least an arm's length away from other residents, encouraging the resident to verbalize the cause for aggression, placing staff between the resident and other residents to prevent altercation, maintaining a consistent schedule with a daily routine, and minimizing environmental stimuli.
A care plan revealed Resident 49 has a problem with impaired thought processes related to dementia initiated on April 15, 2024. Interventions implemented to assist Resident 49 to communicate her basic needs include asking yes/no questions, cueing, reorienting, supervising as needed, and presenting one thought, idea, question, or command at a time.
A review of clinical records and documentation provided by the facility revealed Resident 49 physically abused three residents from November 26, 2024, through February 24, 2025, including slapping Resident 224 in the face, punching Resident 108 in the back of the head, and pushing Resident 104.
A clinical record review revealed Resident 224 was admitted to the facility on [DATE], with diagnoses that included dementia.
A review of an annual MDS assessment dated [DATE], revealed that Resident 224 is severely cognitively impaired with a BIMS score of 03 (a score of 01-07 indicates severe cognitive impairment).
A progress note dated November 26, 2025, at 5:50 PM indicated Resident 224 was slapped in the face by Resident 49 in the dining room. Resident 224 was upset, stating, She just came up to me. Emotional support provided and skin assessment completed; no bruising, bleeding, swelling, or reports of pain assessed.
A progress note dated November 26, 2025, at 5:50 PM indicated Resident 49 was seen slapping Resident 224 in the dining room. No provocation witnessed. Resident 49 slapped Resident 224 behind the back of the one-to-one safety sitter who was between the residents.
A statement form dated November 26, 2024, revealed Employee 8, Nurse Aide (NA), turned around as she heard Resident 49 get upset, standing by Resident 224 at the table in the dining room. Employee 8, NA, indicated Resident 49 backhand slapped Resident 224 in the face.
A statement form dated November 27, 2024, revealed Employee 9, Activities Aide (AA), indicated she was in between Resident 49 and Resident 224 when Resident 49 reached around Employee 9, AA, and hit Resident 224.
A clinical record review revealed Resident 108 was admitted to the facility on [DATE], with diagnoses that include dementia. A review of a quarterly MDS assessment dated [DATE], revealed that Resident 224 is severely cognitively impaired with a BIMS score of 06 (a score of 01-07 indicates severe cognitive impairment).
A progress note dated January 17, 2025, at 9:05 AM revealed Resident 49 spat, punched, and scratched a nurse aide during morning care. Supervision and administration were notified. The note indicated a physician order not to send the resident to the emergency department, and the administration was in agreement.
A progress note dated January 17, 2025, at 1:30 PM revealed Resident 108 was walking in the hallway. Staff witnessed Resident 49, unprovoked, hit Resident 108 on the left side of her head with a closed fist. The residents were separated. Resident 108 was assessed with no open area, scratches, or bruising noted. Resident 108 denied pain.
A progress note dated January 17, 2025, at 1:51 PM revealed that while on a one-to-one (level of observation of one staff member to one resident continuous observation), Resident 49 hit Resident 108 with the back of her hand, with a closed fist. Resident 49 was assessed without injury.
A clinical record review revealed Resident 104 was admitted to the facility on [DATE], with diagnoses that include dementia. A review of a quarterly MDS assessment dated [DATE], revealed that Resident 104 is severely cognitively impaired with a BIMS score of 04 (a score of 01-07 indicates severe cognitive impairment).
A progress note dated February 24, 2025, at 5:34 AM revealed Resident 104's roommate was agitated and trying to spit and hit the nurse aide. Resident 104 asked Resident 49 to stop. Resident 49 shoved Resident 104 on to her bed. Resident 104 was assessed, and no injuries were noted.
A progress note dated February 24, 2025, at 6:42 AM revealed Resident 49 is on a one-to-one. The note indicated Resident 49 slept without incident until 2:00 AM, when she began walking the hallways and became aggressive towards the nurse aide and the roommate, Resident 104. The roommate tried to intervene, Resident 49 pushed her back on the bed, and scratched, punched, and spat at the nurse aide.
A statement form, dated February 24, 2025, revealed Employee 13, Licensed Practical Nurse (LPN), was with Resident 104, beginning on February 23, 2025, at 10:00 PM. Employee 13, LPN, indicated at 2:00 PM Resident 49 began walking the hall, punching, pushing, scratching, and spitting. Redirection was attempted. Employee 13, LPN, indicated Resident 49 pushed Resident 104 because Resident 104 told her to stop.
A clinical record review revealed Resident 37 was admitted to the facility on [DATE], with diagnoses that included hemiplegia (paralysis on one side of the body). A review of a quarterly MDS assessment dated [DATE], revealed that Resident 37 was cognitively intact with a BIMS score of 15 (a score of 13-15 indicates cognition is intact).
A review of the care plan for Resident 37, initiated May 1, 2024, revealed the resident had a very low tolerance for confused and behavioral residents. Documented behaviors included yelling at other residents, calling residents names, making obscene gestures, and swinging at other residents. Interventions to address these behaviors included intervening as necessary to protect the rights and safety of others, praising progress and improvement in behavior, and educating the resident on successful coping and interaction strategies.
A clinical record review revealed Resident 18 was admitted to the facility on [DATE], with diagnoses to include dementia. A review of a quarterly MDS assessment dated [DATE], revealed that Resident 18 was severely cognitively impaired with a BIMS score of 02 (a score of 01-07 indicates severe cognitive impairment).
A progress note dated March 7, 2025, at 7:30 PM, documented that a nurse aide reported Resident 18 had been struck multiple times with the laundry room door by Resident 37. The physician was notified and ordered a STAT X-ray.
A progress note dated March 7, 2025, at 8:45 PM revealed Resident 37 struck Resident 18's left arm multiple times with the laundry room door. Residents were separated, and both residents were assessed for injuries. No injuries were documented in the note.
A witness statement, dated March 7, 2025, completed by Employee 11, Nurse Aide (NA), revealed the employee heard yelling while at the nurses' station. Upon investigation, Employee 11 witnessed Resident 37 slamming the laundry room door against Resident 18's left arm repeatedly. Employee 11 reported running toward the residents, verbally directing Resident 37 to stop. Resident 37 stated, She's going to lock me in the laundry room. Tell her to get out of the way. Employee 11 separated the residents and reported that Resident 37 continued yelling at staff.
A witness statement dated March 7, 2025, completed by Employee 12, Nurse Aide (NA), revealed the employee observed Resident 37 taking the laundry room door and striking Resident 18's left forearm multiple times with the door handle. Employee 12 documented that Resident 37 continued hitting Resident 18 even after staff directed Resident 37 to stop. Staff intervened and separated the residents.
A progress note dated March 10, 2025, at 3:22 PM, documented that Resident 18 sustained an injury to the left arm as a result of the altercation with Resident 37, with Resident 18 reporting pain but no bruising observed. The X-ray results were negative for fracture.
During an interview conducted on April 25, 2025, at approximately 10:00 AM, the Nursing Home Administrator (NHA) confirmed that it is the facility's responsibility to ensure that residents are free from abuse, including abuse between residents. The NHA confirmed that it is the facility's responsibility to ensure that Resident 37 and other residents do not physically abuse other residents.
The facility was aware of the physically aggressive behaviors of Resident 49 but failed to implement effective interventions to prevent the physical abuse of other residents. Also, the facility was aware of Resident 37's low tolerance for confused residents, but failed to implement effective interventions including supervision to prevent the physical abuse of another resident.
A review of Resident 57's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses to include end-stage renal disease (the final stage of kidney decline where the kidneys are no longer able to function to meet the body's needs) dependent on dialysis (the process of removing waste products and excess fluid from the body when the kidneys are unable to adequately filter the blood) and bilateral below-the-knee amputation of his lower extremities.
A review of a quarterly MDS dated [DATE], revealed that Resident 57 had moderately impaired cognition with a BIMS score of 12 (a score of 8-12 indicates cognition is moderately impaired).
Additionally, the MDS was coded that the resident had functional limitations in range of motion with impairments to both sides of the lower extremities, and the resident was identified as dependent with bed-to-chair transfer (the ability to transfer to and from a bed to a chair or wheelchair).
The most current review of a quarterly MDS, dated [DATE], revealed that Resident 57 is cognitively intact with a BIMS score of 14 (a score of 13-15 indicates cognition is intact).
Resident 57's comprehensive person-centered plan of care was initiated on November 23, 2024, and indicated the resident required the assistance of two staff members with transfers and was revised on December 16, 2024, to include the use of a mechanical lift (a mechanical device designed to lift/transfer individuals that have limited mobility in a safe manner and reduce injuries) with transfers.
A review of Resident 57's clinical record revealed physician orders dated December 6, 2024, directed the use of a mechanical lift for all transfers and bed mobility, with the assistance of two staff members.
A review of Resident 57's task report (an electronic record that summarized planned resident-centered tasks completed by nursing) revealed that Resident 57 was an assist of two staff members via the mechanical lift for transferring initiated on December 8, 2024.
A review of a facility investigative report dated December 13, 2024, at approximately 2:30 PM, revealed that Employee 14, an agency nurse aide was transferring Resident 57 and experienced a fall during the transfer.
A review of a witness statement from Employee 14, dated 2:30 PM, indicated he was transferring the resident to his wheelchair and grabbed the resident under both arms, and that Resident 57 was holding onto him with both arms and while during the transfer his left below-the-knee amputation stump became stuck in the wheelchair arm. Employee 14 then called out for help and received assistance from Employee 15, the maintenance director, to help dislodge his stump from the wheelchair arm. Employee 14 then attempted to reposition the resident into the wheelchair but stumbled over clutter on the floor and placed the resident on the floor to prevent harm. The statement did not acknowledge that the mechanical lift, as required by physician order and care plan, had not been used.
A review of a witness statement from Employee 15, dated 2:30 PM, indicated that he heard someone yelling for help and witnessed Employee 14 holding Resident 57 under both arms while Resident 57 had both of his arms wrapped around Employee 14, and Employee 14 asked Employee 15 to help dislodge his left stump from the wheelchair arm. Employee 15 assisted in freeing the resident's stump from the wheelchair arm. After the stump was freed, Employee 14 lost balance and the resident was found lying on the floor. Employee 15 also observed clutter on the floor and water from a bottle that spilled during the incident.
A review of a nurse's incident/accident statement dated December 13, 2024, at 4:21 PM, revealed that they found Resident 57 on the floor lying next to Employee 14 and noted debris of a cup, paper, and water on the floor.
The facility's investigation report lacked documentation of an interview with Resident 57 regarding the incident. The Nursing Home Administrator (NHA) was unable to provide a reason why no statement was obtained from the resident.
A nurse's progress note dated December 14, 2024, at 10:37 AM, indicated that Resident 57 complained of right-sided rib pain following the fall on December 13, 2024. A physician's order was obtained for an x-ray of the right ribs.
An x-ray report dated December 17, 2024, showed no acute or chronic fracture. A physician's progress note dated December 19, 2024, documented a clinical impression of a right rib contusion (bruise) based on the negative x-ray and the resident's continued pain.
A review of Resident 57's Medication Administration Record from December 2024 revealed that he received Tylenol as needed for right rib pain on December 14, 2024, at 8:24 AM for a pain of 8; (pain scale rating of 1 equals no pain 10 equals the worst pain) on December 15, 2024, at 4:22 AM for a pain of 7; and on December 20, 2024, at 9:26 PM for a pain of 3.
An interview with Resident 57 on April 24, 2025, at 8:40 AM, revealed that prior to the transfer, he mentioned to Employee 14 that he required the use of a mechanical lift for transfer with two staff members and that Employee 14 ignored his request. Resident 57 stated that he felt Employee 14 moved him without the lift because he was in a hurry to get it done faster.
An attempt was made to contact Employee 14 via telephone on April 24, 2025, during the on-site survey. The employee could not be reached, and no additional clarification regarding the incident was obtained. Employee 14 was no longer employed by the facility. The NHA could not provide a reason for his departure.
An interview on April 24, 2025, at 11:00 AM with Employee 15 revealed he was unsure why Employee 14 was transferring the resident alone.
A review of Employee 14 personnel file acknowledged that he completed training and was deemed proficient to perform all assigned tasks, including proper transfer techniques, and received training on abuse and neglect of a resident.
Despite this documented competency, the resident's clinical record confirmed that Employee 14 did not follow established care plan and physician-ordered protocols requiring the use of a mechanical lift and two-person assistance when transferring Resident 57 on December 13, 2024.
Despite this documented training and acknowledgment of competency, review of Resident 57's clinical record confirmed that Employee 14 failed to adhere to established care plan and physician-ordered protocols requiring the use of a mechanical lift and two-person assistance when transferring the resident on December 13, 2024.
An interview with the NHA on April 24, 2025, at 1:30 PM, confirmed that the facility failed to ensure staff followed the resident's care plan and physician orders for the use of a mechanical lift with two-person assistance for transfers. The NHA acknowledged that failure to follow these directives resulted in increased pain and discomfort to the resident.
Refer to F610
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a) Resident Rights
28 Pa. Code 211.12 (d)(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 the facility failed to ensure respiratory care including tracheostomy (surgical procedure where a hole is created in...
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Based on observation, clinical record review, and staff interview it was determined the facility failed to ensure respiratory care including tracheostomy (surgical procedure where a hole is created in the neck and a tube is inserted into the trachea or windpipe to help a person breathe) care was provided in accordance with physician orders for one of three sampled residents (Resident 2).
Findings include:
Review of the clinical record revealed Resident 2 had diagnoses which included chronic respiratory failure (condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) with tracheostomy and cerebral palsy (brain disorder that appears in infancy or early childhood and permanently affects body movement and muscle coordination).
A physician order dated February 3, 2025, was noted for a Pulmonary Consult on February 17, 2025.
Review of the Pulmonary Consult dated February 17, 2025, revealed that Resident 2 was weaned to room air (normal air without supplemental oxygen) during the appointment. The plan/medical decision making/recommendations included to use oxygen as needed to maintain O2 level (oxygen saturation- the amount of oxygen carried by red blood cells in blood) was greater than 89%. Maintain humidification (process of adding moisture to the air a person with a tracheostomy breathes, without humidification the air can dry out secretions, making them thick and difficult to clear) via trach even if on room air. Start vest (SmartVest- provides high frequency chest wall oscillation to simulate repetitive mini-coughs to shear mucus away from the walls of the lung's airways and reduce the viscosity [thickness] of secretions) twice daily as tolerated for airway clearance. Use Albuterol (bronchodilator which works by relaxing and opening the air passages to the lungs to make breathing easier) twice daily with vest. Follow-up with pulmonary medicine in three months for evaluation.
A physician order following the Pulmonary Consult dated February 17, 2025, noted to use oxygen as need to keep O2 level greater than 89%. Use humidification for trach. Start vest therapy twice daily to assist with mucous clearance if the resident tolerates. Use Albuterol nebulizer twice daily with vest therapy.
Observation of Resident 2 on April 24, 2025, at 1:25 PM revealed the resident was in bed. Further observation revealed the resident was not receiving oxygen or humidification via the resident's tracheostomy. There was no evidence of a SmartVest in the resident's room.
Interview with Employee 8 (RN) on April 24, 2025, at approximately 1:40 PM confirmed that humidification was not being used for the resident when the resident is on room air. Employee 8 (RN) confirmed the resident had not yet received a SmartVest.
Further review of the clinical record revealed no documented evidence that arrangements had been made to obtain a SmartVest for the resident based on the physician order dated February 17, 2025, for vest therapy twice daily.
Upon surveyor inquiry on April 24, 2025, the facility clarified recommendations from the resident's pulmonary consult on February 17, 2025.
A telephone encounter note dated April 25, 2025, confirmed the resident should be receiving humification when on room air to keep secretions moist and easier for the resident to cough the secretions out or be suctioned. A phone number to obtain a SmartVest was also provided.
Interview with the director of nursing on April 25, 2025, at 12:23 PM failed to provide documented evidence that physician orders related to respiratory and tracheostomy care for Resident 2 were timely implemented.
28 Pa. Code 211.5 (f)(i) Medical records.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of select facility policies, the facility's infection control log, and staff interviews, it was ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, a review of select facility policies, the facility's infection control log, and staff interviews, it was determined the facility failed to maintain and implement a comprehensive infection prevention and control program and failed to implement transmission-based precautions to mitigate the spread of infectious disease for one out of the 27 residents sampled (Resident 56).
Findings included:
A review of a facility policy titled Respiratory Syncytial Virus (RSV) Prevention, last reviewed by the facility on January 22, 2025, revealed it is the facility policy to ensure that residents diagnosed with RSV are placed on contact precautions for the duration of the illness.
A review of a facility policy titled Isolation-Categories of Transmission-Based Precautions, last reviewed by the facility on January 22, 2025, revealed that contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. Staff and visitors are to wear gloves (clean-nonsterile) and a disposable gown when entering the room and remove before leaving the room and to avoid touching potentially contaminated surfaces with clothing after gown is removed.
A clinical record review revealed Resident 56 was admitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD is a condition caused by damage to the airways or other parts of the lung that blocks airflow and makes it hard to breathe) and schizophrenia (a chronic and severe mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions).
A quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 56 dated February 03, 2025, revealed the resident was severely cognitively impaired with a BIMS score of 03 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 0-7 indicates severe cognitive impairment).
A review of Resident 56's clinical record for the laboratory of a respiratory panel, which resulted on April 22, 2025, at 11:11 AM, revealed abnormal results of positive RSV.
A review of Resident 56's clinical record revealed a laboratory result from a respiratory panel collected April 22, 2025, at 11:11 AM, indicated the resident tested positive for Respiratory Syncytial Virus (RSV), an infectious viral illness that requires implementation of transmission-based precautions.
A physician's order dated April 22, 2025, at 12:17 PM, directed that contact precautions 9 prevent the spread of bacteria or viruses by the use of gowns, gloves and masks) be initiated for Resident 56 due to the positive RSV result, to remain in place through May 2, 2025.
However, an observation conducted on April 22, 2025, at 1:30 PM revealed:
No signage was posted outside Resident 56's room indicating that contact precautions were in effect.
No personal protective equipment (PPE), such as gloves or gowns, were available outside the resident's room for staff use.
An interview conducted at the time of observation with Employee 6, Licensed Practical Nurse (LPN), confirmed that Resident 56 required contact precautions due to the RSV diagnosis.
A second observation conducted at 2:20 PM on April 22, 2025, again revealed the continued absence of contact precaution signage and PPE outside the resident's room.
A third observation conducted on April 23, 2025, at 8:10 AM continued to show no signage or PPE readily available for use.
An interview with Employee 7, LPN, conducted during the April 23, 2025, observation, revealed that the nurse was unaware that Resident 56 required contact precautions.
An interview with the Director of Nursing (DON) and Nursing Home Administrator (NHA) on April 23, 2025, at 9:40 AM confirmed the contact precautions ordered for Resident 56 were not implemented as directed by the physician. The NHA further confirmed that the contact precautions were not initiated until approximately 11:00 AM on April 23, 2025, one day after the observation after the order was issued, and only following surveyor inquiry. The NHA confirmed the facility is responsible for ensuring full implementation of infection control procedures, including contact precautions, in accordance with facility policy and nationally recognized infection control guidelines.
A review of a select facility policy titled Infection Prevention and Control Program, last reviewed by the facility on January 22, 2025, revealed it is the facility's policy to establish an infection prevention and control program (IPCP) to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The IPCP provides a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement.
The policy indicates surveillance data and reporting information are used to inform the infection prevention and control committee of potential issues and trends. Data gathered during surveillance is used to oversee infections and spot trends. The policy indicates the infection Preventionist collects data from the nursing units, categorizes each infection by body site (these can also be categorized by organism or according to whether they are facility- or community-acquired), and records the absolute numbers of infections.
A review of the facility's infection control data revealed the facility's infection control program failed to implement an operational system to monitor and investigate causes of infection and manner of spread from November 2024 through April 2025. The facility's surveillance and data analysis system of infectious disease data failed to identify clusters of infection, track changes in prevalent organisms, or identify increases in infection rates in a timely manner.
During an interview on April 25, 2025, at approximately 9:00 AM, the infection Preventionist indicated that she has not been able to keep up with infection control data analysis. She provided handwritten infection surveillance logs from November 1, 2024, through March 18, 2025, that indicated the resident's name, prescribed medication, date range of administered medications, and an incomplete listing of infectious disease category (e.g., urinary tract infection, rash, wound).
The Infection Preventionist, explained that she was behind on her data analysis and surveillance of facility infectious disease. She indicated the last time she was able to fully analyze infectious disease was October 2024.
Additionally, review of the logs from November 2024 through April 2025 indicated the facility failed to consistently document critical infection-related details such as:
Resident room numbers or location in the facility
Identification of organisms as applicable
Indication of whether infections were facility- or community-acquired
Symptoms experienced by residents
Date of infection onset
During an interview on April 25, 2025, at approximately 10:00 AM, the NHA confirmed the facility is responsible for implementing a comprehensive infection control program that includes effective surveillance and timely analysis of infectious disease trends. The NHA was unable to provide documentation demonstrating that the facility had a functional surveillance system capable of tracking infection clusters or analyzing changes in prevalent organisms from November 2024 through April 2025.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
Jun 2024
17 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records and select facility policy, staff and resident interviews, it was determined ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records and select facility policy, staff and resident interviews, it was determined that the facility failed to ensure the self-administration of medications was clinically appropriate for one of the 27 residents sampled (Resident 7).
Findings include:
A review of facility policy titled Self-Administration of Medications, provided by the facility on April 18, 2024, indicated residents have the right to self-administer medications if the interdisciplinary team has determined that is clinically appropriate and safe for the resident. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and care plan.
A clinical record review revealed Resident 7 was admitted to the hospital on [DATE], with diagnoses that include acute respiratory failure (a condition where the respiratory system is unable to remove carbon dioxide from or provide oxygen to the body) and chronic kidney disease (gradual loss of kidney function).
A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated March 29, 2024, revealed that Resident 7 is cognitively intact with a BIMS score of 14 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).
During an interview and observation on June 11, 2024, at 12:00 PM, Resident 7 was observed seated by her bed. On her bedside table were five pills in a small, clear plastic cup. The resident stated that she is unable to swallow them all at once, so the nurses leave the pills by her table, and she takes the medications one at a time as she is able.
During an interview on June 11, 2024, at 12:08 PM, Employee 11, Licensed Practical Nurse (LPN), confirmed that she left the pills with Resident 7 because the resident was unable to swallow them all at once. Employee 11, LPN, was unable to confirm if Resident 7 was assessed or approved to safely self-administer medication.
An authorization of self-administration of drugs {medications} form, with no date indicated, revealed that Resident 7 elected not to exercise her right to self-administer medications.
A clinical record review failed to find documented evidence that Resident 7 was assessed and deemed safe and appropriate to self-administer her medications.
During an interview on June 14, 2024, at approximately 11:00 AM, the Director of Nursing (DON) confirmed that there was no documented evidence that Resident 7 was assessed and deemed safe and clinically appropriate to self-administer her medications. The DON confirmed that without an assessment, Resident 7 should not have been allowed to self-administer her medications.
28 Pa Code: 211.9 (a)(1) Pharmacy services.
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 F0583
(Tag F0583)
Could have caused harm · This affected 1 resident
Based on review of select facility incident reports and staff and resident interview, it was determined that the facility failed to ensure that mail was delivered unopened to one of 11 residents inter...
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Based on review of select facility incident reports and staff and resident interview, it was determined that the facility failed to ensure that mail was delivered unopened to one of 11 residents interviewed during a resident group interview (Resident 106).
Findings include:
Definitions under the regulatory guidance for §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.
During a resident group interview on June 12, 2024, at 11:40 AM, Resident 106 stated that he does not receive his incoming mail and packages unopened. Resident 106 stated in the past there was a mix-up with prescription medication arriving in a package from a healthcare facility addressed to him instead of being sent directly to the facility.
Review of a facility incident report dated May 21, 2024, Resident 106 was found with Buprenophine patches (opioid analgesic, controlled substance) in his room. The patches arrived in a package from a local healthcare clinic where Resident 106 was seen for an appointment. The local healthcare clinic was contacted to address the mistake of sending medication directly to Resident 106 while a resident at the facility. A procedure was put in place that any future packages from the healthcare clinic would be addressed to the care of nursing supervisor for Resident 106.
To avoid similar incidents staff who receive Resident 106's were inserviced on May 29, 2024, to identify and record any packages which arrive for Resident 106 which are addressed care of nursing supervisor and alert the nursing supervisor upon receiving any such packages.
Interview with the director of nursing (DON) on June 13, 2024, at 1:30 PM confirmed that any packages which were received care of nursing supervisor for Resident 106 should still be opened by the resident with the nursing supervisor present. The DON confirmed that there have been no further incidents of Resident 106 receiving packages addressed care of the nursing supervisor. The DON confirmed that Resident 106's mail or packages should not be opened by staff. The DON confirmed that all residents including Resident 106 have the right to receive mail and packages unopened.
28 Pa. Code 201.29(a) Resident rights.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Requirements
(Tag F0622)
Could have caused harm · This affected 1 resident
Based on a clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provid...
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Based on a clinical record review and staff interview, it was determined that the facility failed to ensure that the necessary resident information was communicated to the receiving health care provider for one resident out of 27 residents sampled with facility-initiated transfers (Residents 7).
Findings include:
A clinical record review revealed that Resident 7 was transferred to a community hospital on June 8, 2024, and returned to the facility on June 10, 2024.
A nursing progress note dated June 8, 2024, at 2:09 PM indicated that Resident 7 was sent to the receiving provider and sent with all appropriate paperwork. There was no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, including contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, advance directive information, all special instructions or precautions for ongoing care, as appropriate, and any other documentation, as applicable, to ensure a safe and effective transition of care.
During an interview on June 14, 2024, at approximately 11:30 AM, the Director of Nursing (DON) and Nursing Home Administrator (NHA) confirmed that there was no evidence that the necessary information was communicated to the receiving health care institution or provider for Resident 7's facility-initiated transfers on June 8, 2024.
28 Pa. Code 201.29 (a)(c.3)(2) Resident rights
28 Pa. Code 211.12 (d)(3)(5) Nursing services
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the Resident Assessment Instrument Manual and clinical records, and staff interview, it was determined that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the Resident Assessment Instrument Manual and clinical records, and staff interview, it was determined that the facility failed to timely submit Minimum Data Set (MDS) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, for one of eight sampled (Resident 72).
Findings Include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS) dated [DATE], requires that discharge assessments-return anticipated (non-comprehensive) be completed no longer than the resident's discharge date + 14 calendar days.
A clinical record review revealed that Resident 72 was transferred to the hospital on April 30, 2024.
A progress note dated May 3, 2024, revealed that Resident 72 returned to the facility.
Further review of the clinical record revealed no documented evidence that an MDS discharge assessment-return anticipated (non-comprehensive) was completed for Resident 72.
During an interview on June 13, 2024, at approximately 1:00 PM, the director of nursing confirmed that Resident 72's discharge return anticipated MDS assessment was not completed and submitted within the required timeframes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, and staff interview it was determined that the facility failed to address a re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, and staff interview it was determined that the facility failed to address a resident's active diagnoses and treatment and individualized communication methods and needs on the resident's care plan for one resident out of 27 sampled (Resident 112).
Findings included:
A review of Resident 112's clinical record revealed he was admitted to the facility on [DATE], with diagnosis to include diabetes, Parkinson's disease (a long-term neurodegenerative disease of mainly the central nervous system), and peripheral vascular disease (a slow, and progressive disorder of the blood vessels -
PVD).
A review of the admission Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated December 5, 2023, revealed that the resident is Hispanic, Latino/a, or Spanish in origin, and that Resident 112's preferred language is Spanish (Espaniol and ) and that the resident does need - wants an interpreter to communicate with a doctor or health care staff.
A review of Resident 112's clinical record, Social Determinants of Health notes dated November 30, and December 28, 2023, and March 27, 2024, stating the resident is Hispanic, Latino/a, or Spanish in origin, and his language is Spanish. The resident does need -want an interpreter to communicate.
A nurses note dated January 2, 2024, at 1655 (4:55 PM) indicated that a language barrier was noted as the resident does not speak English. A CNA (certified nursing assistant) was present, speaks Spanish and was assisting with translation.
An observation on June 11, 2024, at approximately 11:10 AM, revealed no visible communication tool, such as a communication board or translation device available to aid the resident in communication with others.
A second observation and attempted interview with Resident 112's, in his room on June 11, 2024, at approximately 11:55 AM, upon entering the room, the alert resident sat up in his bed and smiled. In the presence of Employee 1, nurse aide (NA), the observation of the residents room to include his wardrobe, dresser, nightstand, and wheelchair revealed no visible communication device, board, tablet, or picture book, was available to aid communication with the resident.
At this time, Employee 2, Licensed Practical Nurse (LPN), confirmed the observation, and stated the facility utilizes the services of a phone interpreter. However, the observation of Resident 112's room failed to reveal the contact information for the interpreter, phone number, and or directions to access the service.
A review of Resident 112's care plan in effect during the survey ending June 14, 2024, indicated the residents admission date was November 29, 2023, and revealed that the resident's comprehensive care plan did not include the resident's known conditions to include Parkinson's disease, PVD, nor his preferred language, and or any assistive devices to be used in an attempt to communicate with Resident 112.
During an interview with the Director of Nursing (DON) on June 12, 2024, at approximately 9:10 AM, confirmed facility failed to fully develop and implement person-centered comprehensive care plan in a manner that assures staff are aware of the resident's specific and individualized interventions to address a resident's health needs, including communication methods.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, and staff interviews, it was determined that the facility failed to thoroughly assess and e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, and staff interviews, it was determined that the facility failed to thoroughly assess and evaluate bladder function and implement individualized interventions to restore bladder function to the extent possible for one resident (Residents 47), andprovide care and services to prevent potential complications with the use of an indwelling foley catheter (a flexible tube which is placed into the bladder to drain urine) for one resident out of two sampled with a foley catheter (Resident 101).
Findings include:
Department of Health & Human Services, USA. Centers for Disease Control and Prevention, Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009, last updated June 6, 2019, III Proper Techniques for Urinary Catheter Maintenance, B. Maintain unobstructed urine flow. 2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.
Review of Resident 47's clinical record revealed admission to the facility on August 9, 2022, with diagnoses that included Parkinson's disease (a long-term neurodegenerative disease of mainly the central nervous system), diabetes, and hypertension.
A review of the residents Quarterly Minimum Data Set Assessments (MDS - a federally mandated standardized assessment completed at specific intervals to define resident care needs) dated May 12, 2023, Annual MDS dated [DATE], and Quarterly MDS dated [DATE], Section H Bladder and Bowel, all indicated the resident was coded a (2) indicating frequently incontinent of bladder.
Resident 47's Quarterly MDSs dated February 12, 2024, and May 14, 2024, Section H Bladder and Bowel, noted that the resident was always incontinent of bladder (a decline of urinary bladder function).
The resident's plan of care for bladder incontinence, date-initiated August 16, 2022, revealed planned measures included to check the resident per protocol and as required for incontinence, monitor/document for sign/symptoms of UTI, urinary frequency, change in behavior, and preventative skin care per protocol.
During an interview with the Director of Nursing (DON) on June 12, 2024, at approximately 1:50 PM, it was confirmed that there was no documented evidence that the facility had recognized the increased urinary incontinence and completed incontinence evaluations or implemented any scheduled toileting programs in response to the resident's decline in bladder function.
A review of Resident 101's clinical record revealed admission to the facility on January 22, 2024, with diagnosis to include benign prostatic hyperplasia (BPH- age-associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms, retention of urine, and Alzheimer's disease.
The resident had a physician order, initially dated May 22, 2024, for a foley catheter (a flexible tube inserted through the urinary opening (urethra) and into the bladder. The device drains the urine into a drainage bag).
Observation of Resident 101 in the resident's room on June 11, 2024, at 10:40 AM revealed that the resident was lying in bed with the bed lowered close to the floor. The resident's urinary collection bag, which was attached to the base of the bedframe, was directly in contact with the floor without a barrier or additional protective covering.
Further observation of Resident 101, accompanied by Employee 5 (Licensed Practical Nurse), in the resident's room, on June 13, 2024, at 9:48 AM, revealed that the resident's bed was in a low position with the urinary collection bag directly in contact with the floor and without a barrier or protective covering.
Interview with Employee 5, on June 13, 2024, at 9:50 AM confirmed that the collection bag should not have been directly in contact with the floor to prevent urinary tract infection.
Interview with the Director of Nursing (DON) on June 14, 2024, at approximately 11:00 AM confirmed that the facility failed to maintain Resident 101's foley catheter in a manner to prevent potential infection.
28 Pa. Code 211.12 (d)(5) Nursing services
28 Pa. Code 211.10 (a)(d) Resident care policies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Basedonobservation, clinicalrecordreview, andstaffinterview itwasdeterminedthatthefacilityfailedtofailedtotimelyimplementanutritionalsupportregimentomeetthenutritionalneedsandpreventweightlossforonere...
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Basedonobservation, clinicalrecordreview, andstaffinterview itwasdeterminedthatthefacilityfailedtofailedtotimelyimplementanutritionalsupportregimentomeetthenutritionalneedsandpreventweightlossforoneresident (Resident 90) and failed toaccuratelymonitorafluidrestrictionprescribedtoaddressaresidentsclinicalconditionandmaintainfluidbalanceandadequatehydrationstatusforoneresident(Resident178) outof27 sampled.
Findingsinclude
AreviewofafacilitypolicyWeightAssessmentandIntervention lastreviewedbythefacilityApril18, 2024, indicatedthatresidentweightsaremonitoredforundesirableorunintendedweightlossorgain Residentsareweigheduponadmission weeklyx4 weeks andthenmonthlyorperphysicianorders Iftheweightlossis5-pounddifferencefromthelastweight areweightwillbeobtainedandvalidated Thedieticianwillreviewtheweightrecordtofollowindividualweighttrends Thethresholdforsignificantunplannedandundesiredweightlossisbasedonthefollowingcriteria
a
1 month- 5% weightlossissignificant greaterthan5% issevere
b
6 months- 10% weightlossissignificant greaterthan10% issevere
Thepolicyfurther indicatedthatundesirableweightchangeisevaluatedbythephysiciananddietitian Thephysicianandmultidisciplinaryteamidentifyconditionsandmedicationsthatmaybecausinganorexia weightlossorincreasingtheriskofweightloss
ReviewofResident90'sclinicalrecordrevealedthattheresidentwasadmitted tothefacilityonMay22, 2024, withdiagnosestoincludeosteomyelitis(inflammationofthebonecausedbyaninfection, musclewastingandatrophy
AreviewofResident90'scareplan, initiatedMay23, 2024, identifiedthattheresidentmaybenutritionallyatriskrelatedtodietrestrictions obesity weightlossandvariablePOintake andskinintegrity Theresidentsgoalwastoconsumeatleast50% ofatlest2 mealsdailyandmaintainweightwithin3% ofCBW(currentbodyweight. Plannedinterventionsincludedtoassistwithmealsasneeded monitordocumentreportrefusalstoeat andfortheregistereddietitiantomakedietchangerecommendationsasneeded
ReviewofResident90'sresidentsweightrecordrevealed
May22, 2024
160.2 pounds
May29, 2024
157.8 pounds
June6, 2024
149.2 pounds- 6.87% significantweightloss
TherewasnoevidenceofareweightbeingobtainedtoconfirmResident90'ssignificantweightlossasperfacilitypolicyTherewasnoevidencethatfacilitynotifiedResident90'sphysicianofthe6.87% significantweightlossinoneweek
Areviewoftheresidentssurveydocumentationreport(acomputergeneratedreportthatrecordsthedatathatnurseaidesenterformealconsumptionandothercaretasksperformed datedJune2024, revealedthatfromJune1, 2024, throughJune13, 2024, Resident90 refused8 mealsoutof37 servedmeals consumed25% orlessfor8 meals andconsumed50% orlessfor9 meals Residentsconsumptionof51% to100% ofmealsoccurredonly12 timesoutof37 mealsserved
ObservationonJune12, 2024, at7:50 AM revealedResident90 inbed positionedupright asleep Herbreakfasttraywaspositionedinfrontofher untouched Resident90 wasobservedtobealonewithnostaffpresenttoprovideassistance
TherewasnoindicationthatthefacilityidentifiedandacteduponResident90'sweightlossandhaddeterminedifnutritionalsupportinterventionswerenecessary to prevent further weight loss. Therealsowasnoindicationthatthephysician andresidentrepresentativewereinformedofthesignificantweightloss
ThefacilityfailedtoidentifyResident90'sweightloss failedtoidentifyandactuponherdecreasedmealintakes failedtoprovidefeedingassistanceasneededasindicatedinherplanofcare andfailedtoimplementnutritionalsupporttopreventfurtherweightloss Therewasalsonoevidencethatthefacilityhadnotifiedtheresidentsattendingphysicianandresidentrepresentativeofthesignificantweightloss
InterviewwiththeDirectorofNursingonJune14, 2024, at8:30 AM confirmedthatthefacilityfailedtotimelyidentify address andimplementweightlossinterventionstoimproveResident90'snutritionalstatus
ClinicalrecordreviewrevealedthatResident178 wasadmitted tothefacilityonJune5, 2024, withdiagnoseswhichincludedcongestiveheartfailure(achronicconditioninwhichtheheartdoesnotpumpbloodaswellasitshould.
AphysicianorderdatedJune6, 2024, was notedfora1500 ccfluidrestriction
ReviewofResident178'slunchmealtagonJune11, 2024, revealednoevidencethattheresidentwasonafluidrestriction
Furtherreviewoftheclinicalrecordrevealednodocumentedevidencethatthephysicianprescribedfluidrestrictionwasimplementedtoensurethattheresidentdidnotexceed1500 ccsoffluidperday
DuringaninterviewJune13, 2024, atapproximately10:00 AMtheDirectorofNursingconfirmedthatthefacilityfailedtoimplementthephysicianprescribedfluidrestrictionforResident178.
28 Pa Code 211.12 (c(d(3)(5) Nursingservices
8 Pa Code211.5(f Medicalrecords
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 observation, a review of clinical records, and staff interview it was determined that the facility failed to ensure the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records, and staff interview it was determined that the facility failed to ensure the ready availability of necessary emergency supplies for one resident out of two sampled receiving hemodialysis (Resident 59).
Findings include:
According to the National Kidney Foundation, patients receiving hemodialysis should keep emergency care supplies on hand.
A review of the clinical record revealed that Resident 59 was admitted to the facility on [DATE], with a diagnosis to include end stage renal disease, and dependence on renal dialysis (process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood).
Resident 59's clinical record indicated he was receiving hemodialysis through a right upper chest Tesio port (dialysis access site) for dialysis access every Tuesday, Thursday and Saturday.
Resident 59's clinical record revealed a physician order dated June 11, 2024, for an emergency kit at bedside for the dialysis port .
The resident's plan of care, dated May 26, 2024, indicated that staff are to check for a pressure dressing and clamp at bedside for emergency care of the port every shift and document in the Treatment Administration Record (TAR).
Observation conducted on June 11, 2024, and at 12:20 PM and on June 12, 2024, at 8:20 AM revealed no emergency kit or supplies available at the resident's bedside.
Interview with Employee 4 (registered nurse supervisor) on June 12, 2024, at 8:28 AM, revealed that each resident in the facility receiving dialysis should have emergency supplies at bedside. Employee 4 confirmed that there were no emergency supplies available at Resident 59's bedside.
Interview with the Director of Nursing on June 14, 2024, at approximately 11:00 AM confirmed the facility failed to assure an emergency kit was readily available in the event of an emergency with the resident's dialysis access site.
28 Pa. Code 211.12 (d)(3)(5) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, it was determined that the facility failed to provide care in a manner and environment that promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, including experiences reported by nine out of the 11 residents during a resident group interview (Residents 6, 18, 24, 37, 41, 51, 83, 107, and 114).
Findings include:
During a resident group interview with alert and oriented residents on June 12, 2024, at 10:00 AM, the residents in attendance expressed concerns regarding the long wait times for staff to provide assistance with their care when requested/needed.
During the resident group interview, Resident 6 stated that when she needs assistance for care, she waits 15 to 20 minutes for staff to provide the needed care.
During the resident group interview, Resident 18 stated that she waits a very long time for staff to provide needed assistance with care. She explained that staff will sometimes initially respond to her calls for assistance and say they will assist her shortly, but do not come back to provide the needed care. She stated that she often attempts to change and clean herself, even though she understands it is unsafe for her to ambulate without staff assistance. She explained that it bothers her when she is dirty from soiling her brief. Resident 18 also stated that if she wants a shower after soiling herself, staff tells her that she can only take a shower on her scheduled shower days twice a week. Resident 18 stated that she often asks for clean linens for her bed but staff tell her that she is only allowed clean linens on her shower days twice a week. She explained that she would change the sheets herself, but staff refused to provide her clean bed linens. Resident 18 also stated that sometimes nursing staff send the residents to common areas or programs without helping them get dressed. She stated that she was sent to the dining room in her nightgown, and that these experiences make her feel terrible.
During the resident group interview, Resident 24 expressed that she is upset when staff tells her that she is not allowed to ring her call bell for assistance when meals are being passed out at breakfast, lunch, or dinner. She explained that the staff tell her that she needs to go to the bathroom before the meal or wait until after meal service. She stated that she sometimes must sit in her urine or feces while she waits for staff assistance. Resident 24 expressed that it makes her angry because she is over [AGE] years old and can't hold it when she needs to use the bathroom. She stated that she is not sure how long it takes for staff to respond, but often longer than her body could wait. Resident 24 stated that she has been taking herself to the bathroom, even though she knows it is unsafe for her to do so.
During the group interview, Resident 37 stated that she is upset that she waits 15-20 minutes for staff to respond to her call bell when she needs assistance. She explained that nursing staff will initially respond, turn her call bell off, but leave without providing her care. She stated that she would holler and yell until someone responds. Resident 37 said it bothers her when she must wait 15 minutes for staff when seated on the toilet because it hurts to sit so long.
During the group interview, Resident 41 stated that she often waits 45 minutes for care from staff when needed. She explained that she is on a medication that causes her to frequently urinate and often needs her brief changed. Resident 41 stated that she often sits in a urine puddle, waiting for staff assistance. She explained that if she needs to be changed in the morning, staff will tell her after breakfast and tell her you need to wait. Resident 41 indicated that it upsets her because she does not want to sit in her urine.
During the group interview, Resident 51 stated that she waits 45 minutes to an hour for care from staff when needed. She explained that after 15 or 20 minutes of waiting for staff to respond to her call bell ring for assistance, she will use her cell phone to call the nursing station or the front desk. Also, she stated that staff will call her cellphone instead of physically checking on her when she rings her call bell for assistance.
During the group interview, Resident 83 stated that he tries to care for himself as much as possible. He explained that last week staff did not respond to his call-bell for assistance, and he had to use his cell phone to get staff to bring him a cup of water. Resident 83 stated that it took him an hour to get a drink of water.
During the group interview, Resident 107 stated that she waits a long time to receive care after ringing her bell for assistance. She explained that she waits 15 minutes or longer for care. Resident 107 expressed that she is upset when she is not allowed to have a shower, and nursing staff tell her she can only shower on her scheduled days twice a week. She stated that she enjoys feeling clean and wants to be able to shower more often than twice a week.
During the group interview, Resident 114 stated on several recent occasions, she has waited over an hour for care after ringing her call bell for assistance. She expressed anger and frustration that she has to sit in her soiled brief because she does not have the ability to clean herself. Resident 114 stated that she had loose stools and had to sit in the dirty brief for 45 minutes. She explained that sometimes she will ring for assistance, and staff will walk right past her door without looking or saying a word to her. Resident 114 expressed frustration that staff refuse to change her during meal times, forcing her to remain in a soiled brief until the meal service is over. Resident 114 also expressed being upset when staff tell her during the early afternoon that if we change you now, then you have to stay in bed the rest of the day. She is angry and frustrated because she can't control when she soils herself and needs staff assistance with care.
During an interview on June 14, 2024, at approximately 11:00 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) verified that all residents at the facility should be treated with dignity and respect. The NHA and DON were unable to explain why residents are reporting (1) untimely staff responses to residents' requests for assistance, (2)staff refusing to shower residents at there desired frequency, (3) staff refusing to provide residents with clean linens, and (4) residents being told not to ring their call bells during meals, which is negatively affecting their quality of life in the facility.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 201.29 (a) Resident Rights
28 Pa. Code 211.12 (c) Nursing services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy and investigative reports, and staff interviews, it was determined...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select facility policy and investigative reports, and staff interviews, it was determined that the facility failed to ensure that four residents out of 30 sampled were free from physical abuse (Residents 62, 85, 97, and 119).
Findings include:
A facility policy titled Abuse Prevention Program, reviewed on April 18, 2024, revealed it is facility policy that residents have the right to be free from abuse, including physical abuse. Further policy review revealed that the administration will implement protocols to protect residents from abuse by anyone, including other residents.
A clinical record review revealed Resident 62 was admitted to the facility on [DATE] with diagnoses that include dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated May 2, 2024, revealed that Resident 62 is severely cognitively impaired with a BIMS score of 3 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 01-07 indicates severe cognitive impairment).
A clinical record review revealed Resident 85 was admitted to the facility on [DATE], with diagnoses that include dementia. A review of quarterly, MDS dated [DATE], Section C - Cognitive Patterns, C1000, revealed that Resident 85 has severe impairment to make decisions regarding tasks of daily life. The MDS indicates that a BIMS assessment should not be completed because the resident is rarely or never understood.
A clinical record review revealed that Resident 97 was admitted to the facility on [DATE], with diagnoses that include alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks). and dementia.
A review of a quarterly MDS dated [DATE] revealed that Resident 97 is severely cognitively impaired with a BIMS score of 3 (a score of 01-07 indicates severe impairment).
A plan of care indicating that Resident 97 has a behavior problem related to dementia with episodes of agitation, confusion, aggressive episodes, and physical aggression was initiated on March 16, 2023, with revisions on October 19, 2023. Interventions include administering medication as ordered, providing positive interactions, anticipating and meeting the resident's needs, decreasing the overstimulating environment by walking with the resident to a calmer area, attempting to engage the resident in conversation or activity involving cars, avoiding violent movies or shows, offering a program of activities of interest, providing quiet space, and redirection.
A clinical record review revealed Resident 119 was admitted to the facility on [DATE], with diagnoses that include alzheimer's disease and dementia. A review of admission MDS dated [DATE] revealed that Resident 119 is severely cognitively impaired with a BIMS score of 3 (a score of 01-07 indicates severe impairment).
A review of incident and investigation reports revealed Resident 97 elbowed Resident 62 in the chest on February 19, 2024.
A review of incident and investigation reports revealed Resident 97 pushed Resident 85, causing her to fall to the floor on April 2, 2024.
A review of incident and investigation reports revealed Resident 97 hit Resident 62 in the back of the head and Resident 62 hit Resident 97's right arm on May 26, 2024.
A review of incident and investigation reports revealed Resident 97 hit Resident 119's head twice with a closed fist on June 9, 2024.
A witness statement dated February 19, 2024, indicated that Employee 6, Nurse Aide, witnessed Resident 97 elbow Resident 62 in his chest. Employee 6, Nurse Aide, explained that she yelled for help, and staff were able to separate the residents.
A nursing note dated February 19, 2024, at 5:42 PM indicated that a Registered Nurse assessment was completed and Resident 62 had no injuries.
A nursing note dated February 19, 2024, at 5:49 PM indicated that a Registered Nurse assessment was completed and Resident 97 had no injuries.
A social services progress note dated February 20, 2024, at 2:05 PM revealed that Resident 97 had no recollection of the incident, and no ill effects were noted. The entry noted that Resident 97 denied concerns and complaints and responded well to support and encouragement.
A social services progress note dated February 20, 2024, at 2:08 PM revealed that Resident 119 was pleasantly confused, had no recollection of the event, and presented no signs or symptoms of distress. Resident 119 denied concerns and complaints and responded well to support and encouragement.
A witness statement dated April 2, 2024, indicated that Employee 7, Nurse Aide, was in the dining room and saw Resident 97 push Resident 85, causing the resident to lose her balance and fall to the floor.
A clinical record review revealed no evidence that Resident 85 was assessed for injury on April 2, 2024, after Resident 97 pushed the resident to the floor.
A social services note dated April 3, 2024, at 1:10 PM indicated that Resident 85 was seen following the incident during which Resident 97 pushed Resident 85 to the floor. The note indicated that Resident 85 was pleasant throughout the conversation, smiling appropriately, and had no recollection of the incident. The resident appeared with no signs or symptoms of acute distress or discomfort.
A social services note dated April 3, 2024, at 1:10 PM indicated that Resident 97 reported that he had no recollection of the event, no concerns or complaints regarding his peer, and appeared with no signs or symptoms of acute distress or discomfort.
A witness statement dated May 26, 2024, indicated Employee 8, Nurse Aide, was in the activity room when Resident 97 got up and smacked Resident 62 on the back of the head.
A witness statement dated May 26, 2024, indicated that Employee 9, Nurse Aide, was in the dining room when Resident 97 stood up and aggressively smacked Resident 62 in the back of his head. Resident 62 then smacked Resident 97 on the arm. Nurse Aide, indicated he intervened and separated the residents.
A progress note dated May 26, 2024, at 5:36 PM revealed that Resident 97 was assessed with no injuries noted.
A progress note dated May 26, 2024, at 5:40 PM revealed that Resident 62 was assessed with no injuries noted.
An incident note dated June 9, 2024, at 12:30 PM indicated Resident 119 was struck by another resident in the dayroom. The note indicated that the resident had no apparent injuries and denied pain.
A witness statement, dated June 9, 2024, revealed that Employee 10, Licensed Practical Nurse, received a report that Residents 97 and 119 were arguing when Resident 97 punched Resident 119. Residents were separated and assessed for injuries.
A witness statement dated June 9, 2024, revealed that Visitor 1 was in the activity room visiting with her mom when she saw Resident 97 yell at Resident 119 and hit him in the head. She indicated that she went to get help.
A witness statement dated June 9, 2024, revealed that Visitor 2 witnessed Resident 97 hit Resident 119.
A social service note, dated June 11, 2024, at 9:02 AM, indicated Resident 97 had no issues or concerns and was offered support.
A social service note, dated June 11, 2024, at 9:05 AM, indicated Resident 119 had no issues or concerns and was offered support.
During an interview on June 14, 2024, at approximately 11:00 AM, the DON (director of nursing) and NHA (nursing home administrator) confirmed the facility failed to protect the above residents from physical abuse perpetrated by other residents. The DON and NHA confirmed that residents have the right to be free from abuse, including physical abuse perpetrated by other residents.
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a) Resident Rights
28 Pa. Code 211.12(d)(5) Nursing Services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
Based on a review of clinical records and select facility policy, staff, and resident interviews, it was determined the facility failed to provide written notice of the facility's bed hold policy to a...
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Based on a review of clinical records and select facility policy, staff, and resident interviews, it was determined the facility failed to provide written notice of the facility's bed hold policy to a resident and the resident's representative upon the resident's transfer to the hospital for eight residents out of the 27 sampled (Residents 7, 114, 101, 9, 63, 112, 2, and 106).
Findings include:
A review of facility policy titled Bed-Holds and Returns, last reviewed on April 18, 2024, revealed it is the facility's policy to inform all residents and/or resident representatives in writing of the facility and state bed-hold policies. The policy indicates that all residents and resident representatives, regardless of payor source, are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence at least twice: (1) on admission and (2) at the time of transfer (if the transfer was an emergency, within 24 hours).
A clinical record review revealed that Resident 114 was transferred to the hospital on March 11, 2024, and returned to the facility on March 15, 2024.
A clinical record review revealed no documentation that Resident 114 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital.
During an interview on June 11, 2024, at 10:45 AM, Resident 114 stated that she didn't know she was going to lose her room and was very upset when she returned to the facility and was placed in a new room. She stated that she was never provided any written or verbal notification when she was transferred to the hospital. Resident 114 explained that she learned that she lost her room upon return to the facility, which was five days after transfer to the hospital.
A clinical record review revealed that Resident 7 was transferred to the hospital on June 8, 2024, and returned to the facility on June 10, 2024.
A nursing progress note dated June 8, 2024, at 2:09 PM indicated that Resident 7 was sent to the receiving provider and sent with all appropriate paperwork.
Further review revealed no documentation that Resident 7 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital.
A clinical record review revealed that Resident 101 was transferred to the hospital on March 3, 2024, and returned March 15, 2024. The resident was again transferred to the hospital on March 30, 2024 and returned April 2, 2024.
Further review revealed no documentation that Resident 101 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital on March 3, 2024 or March 30, 2024.
A clinical record review revealed that Resident 63 was transferred to the hospital on December 5, 2023, and returned December 7, 2023. The resident was again transferred to the hospital on January 5, 2024, and returned January 9, 2024.
Further review revealed no documentation that Resident 63 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to a community hospital on December 5, 2023 or January 5, 2024.
A clinical record review revealed that Resident 112 was transferred to the hospital on December 22, 2023, and returned December 28, 2023, on January 2, 2024, and returned January 4, 2024, on February 19, 2024, and returned on February 27, 2024, on March 6, 2024, and returned March 11, 2024, and on March 21, 2024, and returned on March 25, 2024. The resident was again transferred to the hospital on May 20, 2024, and returned May 24, 2024.
Further review revealed no documentation that Resident 112 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital on December 22, 2023, January 2, 2024, February 19, 2024, March 6, 2024, March 21, 2024, and May 20, 2024.
A clinical record review revealed that Resident 2 was transferred to the hospital on March 28, 2024, and returned May 24, 2024.
Further review revealed no documentation that Resident 2 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital on March 28, 2024.
A clinical record review revealed that Resident 106 was transferred to the hospital on May 3, 2024, and returned May 11, 2024.
Further review revealed no documentation that Resident 106 was made aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital on May 3, 2024.
During an interview on June 14, 2024, at approximately 11:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were unable to provide evidence that the facility made Residents 7, 114, 101, 63, 112, 2, and 106 or the residents' representatives aware of a facility's bed-hold and reserve bed payment policy upon transfer to the hospital.
28 Pa Code 201.18 (e)(1) Management
28 Pa Code 201.29 (b) Resident rights
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policy and clinical records and staff interview, it was determined that the facility failed t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of select facility policy and clinical records and staff interview, it was determined that the facility failed to provide restorative nursing services planned to maintain mobility and functional abilities of four of 27 residents sampled (Residents 63, 114, 72, and 2).
Findings included:
A review of facility policy titled Restorative Nursing Services, last reviewed by the facility on April 18, 2024, revealed that it is the facility policy that residents will receive restorative nursing care as needed to help promote optimal safety and independence. The policy indicates restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care.
A review of the clinical record of Resident 63 revealed admission to the facility on September 13, 2023, with diagnoses to include cerebrovascular disease (stroke), hemiplegia (one sided paralysis - weakness) and hemiparesis (one sided weakness) following cerebral infarction affecting left non-dominant side, muscle weakness, difficulty in walking, muscle wasting and atrophy, and lack of coordination.
A review of Resident 63's Occupational Therapy (OT) Discharge summary dated [DATE], indicated that the resident was receiving OT services from September 14, 2023, to September 20, 2023, and that the discharge recommendations were to receive restorative range of motion program.
A Rehab Discharge Recommendation form: Occupational Therapy dated September 20, 2023, indicated that the resident was to receive restorative services, active range of motion (AROM)/active assist range of motion (AAROM)/passive range of motion (PROM), of bilateral upper extremity (BUE) and bilateral lower extremity (BLE) as tolerated.
During an interview on June 13, 2024, at approximately 9:10 AM, with the Director of Therapy Services, confirmed Resident 63 should have received restorative range of motion program, from September 20, 2023, to the present.
A review of the resident's clinical record to include the Documentation Survey Report v2 from September 2023, through the survey ending June 14, 2024, revealed that Resident 63's restorative range of motion program was not implemented, as recommended by the OT discharge summary, and the Rehab Discharge Recommendation form: Occupational Therapy.
Interview with the Director of Nursing (DON) on June 13, 2024, at approximately 9:30 AM failed to provide documented evidence that Resident 63 was provided with the restorative range of motion program.
A clinical record review revealed that Resident 114 was admitted to the facility on [DATE], with diagnoses to include cauda equina syndrome (a condition that occurs when the nerve roots in the lumbar spine are compressed, cutting off sensation and movement).
A review of a quarterly Minimum Data Set assessment dated [DATE] revealed that Resident 114 is cognitively intact with a BIMS score of 15.
A physical therapy Discharge summary dated [DATE], revealed that Resident 114's functional status at discharge was given to the restorative nursing program coordinator.
A physical therapy rehab discharge recommendation form, dated March 10, 2024, indicated that the resident would benefit from active and passive lower extremity range of motion and strengthening while in bed and while seated on the resident's hips, knees, and ankles.
Resident 114's care plan noted the problem of impaired physical mobility and lower extremity weakness related to Caude Equina syndrome initiated on February 8, 2024. There was no documented evidence that recommendations for active range of motion or passive range of motion exercise interventions were incorporated into Resident 114's plan of care.
A certified registered nurse practitioner note dated April 9, 2024, at 2:47 PM indicated that Resident 114 should be on restorative therapy while not on physical therapy for strengthening to not lose muscle tone.
During an interview on June 11, 2024, at 10:45 AM Resident 114 stated that her therapy services ended in March 2024. She explained that she spoke with therapy staff and nursing staff about her interest in participating in restorative nursing services on several occasions. She indicated that staff do not provide her with active or passive exercises. She indicated that she had a meeting last month specifically to address this issue; however, no services were implemented. Resident 114 stated that it is very important for her to participate in any program that would assist her in her physical recovery.
During an interview on June 14, 2024, at approximately 11:00 AM, the Director of Nursing (DON) confirmed that Resident 114's care plan was not updated to include physical therapy restorative program recommendations for active range of motion and passive range of motion exercise interventions. The DON was unable to provide evidence that Resident 114 was receiving active range of motion exercises while seated and while in bed for her hips, knees, or ankles, consistent with physical therapy recommendations and the resident's individual goals.
A review of the clinical record of Resident 72 revealed admission to the facility on May 17, 2023, with diagnoses to include poliomyelitis (polio- illness caused by a virus that mainly affects nerves in the spinal cord or brain stem).
A review of Resident 72's Physical Therapy Discharge summary dated [DATE], indicated that the resident was receiving services from February 8, 2024, to February 22, 2024, and that the discharge recommendations were to receive restorative range of motion program.
During an interview on June 13, 2024, at approximately 9:30 AM, with the Director of Therapy Services, confirmed Resident 72 should have received restorative range of motion program upon conclusion of physical therapy on February 22, 2024.
Further review of the clinical record revealed no documented evidence that a restorative range of motion program was implemented for Resident 72.
Interview with the Director of Nursing (DON) on June 13, 2024, at approximately 9:45 AM failed to provide documented evidence that Resident 72 was provided with the restorative range of motion program.
A review of the clinical record of Resident 2 revealed the resident was admitted to the facility on [DATE], with diagnoses to include cerebral palsy (group of conditions that affect movement and posture caused by damage to the developing brain most often before birth).
A review of Resident 2's Rehab Discharge Recommendation from Physical Therapy dated May 28, 2024, indicated that the resident was recommended for restorative lower extremity range of motion/strengthening.
Further review of the clinical record revealed no documented evidence that a restorative range of motion program was implemented for Resident 2.
Interview with the Director of Nursing (DON) on June 13, 2024, at approximately 9:45 AM failed to provide documented evidence that Resident 2 was provided with the restorative range of motion program.
28 Pa. Code: 211.5(f) Medical records
28 Pa. Code: 211.12(c)(d)(3)(5) Nursing services
28 Pa. Code 211.10 (a)(c)(d) Resident care policies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0694
(Tag F0694)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select facility policy, and staff and resident interviews it was determined that the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select facility policy, and staff and resident interviews it was determined that the facility failed to ensure that physician ordered intravenous antibiotics were administered as prescribed for two residents out of 27 sampled (Resident 86 and 72).
Findings include:
Review of a facility policy titled Administering Medications last reviewed by the facility on April 18, 2024, indicated that medications are administered in a safe and timely manner. It indicated that medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and/or the need for additional staffing. Prescribed medications are to be administered within one hour of their prescribed time, unless otherwise specified.
Review of Resident 86's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include quadriplegia (paralysis of all four limbs), infection and inflammatory reaction due to indwelling urethral catheter (a flexible tube which is placed into the bladder to drain urine), and sepsis (life-threatening complication of an infection).
A physician order dated April 29, 2024, was noted for a Vancomycin HCL (an antibiotic used to treat bacterial infections) Intravenous Solution 1250 MG/250 ML, use 1250 mg intravenously two times a day for sepsis until June 3, 2024, 23:59, flush with 10cc NSS pre/post admin. To be administered by an RN only.
During an interview with Resident 86 on June 11, 2024, at 2:00 PM, he reported that when receiving his IV medication of Vancomycin, nursing staff were often late in hanging his IV. He reported that he was scheduled to receive his dose of IV antibiotics at 12:00 AM and 12:00 PM but that frequently he did not receive his IV medication until 2 or more hours after I was due to receive it.
Review of Resident 86's Medication Administration Record (MAR) for May 2024, indicated that he was scheduled to receive Vancomycin at 0000 hours (12:00AM) and 1200 hours (12:00 PM). The MAR indicated that on May 10, 2024, the 1200-hour (12:00 PM) dose was not administered as scheduled.
Review of nursing progress notes for May 10, 2024, revealed no documentation of the reason for the missed dose of Vancomycin nor was there any documentation to indicate the physician was notified of the missed dose.
Review of a facility-provided real-time administration detail report (a report that indicates the actual time the medication was administered) for administration of IV Vancomycin from April 29, 2024, to May 29, 2024, revealed that on the following dates Resident 86's IV Vancomycin medication was administered one hour or more beyond the physician prescribed time:
May 3, 2024
1:27 PM - one hour and 27 minutes overdue
May 6, 2024
2:57 PM - two hours and 57 minutes overdue
May 15, 2024
1:20 PM - one hour and 20 minutes overdue
May 18, 2024
1:36 PM - one hour and 36 minutes overdue
May 21, 2024
2:43 PM - two hours and 43 minutes overdue
May 23, 2024
1:18 PM - one hour and 18 minutes overdue
Interview with the Director of Nursing (DON) on June 13, 2024, at 12:00 PM, confirmed that the facility failed to timely administer 6 doses of the IV antibiotic therapy prescribed for Resident 86, and failed notify the attending physician of a missed dose.
Review of Resident 72's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include poliomyelitis (polio- illness caused by a virus that mainly affects nerves in the spinal cord or brain stem) and sepsis secondary to chronic infected wounds.
A physician order dated May 3, 2024, was noted for a Vancomycin HCL (an antibiotic used to treat bacterial infections) Intravenous Solution 500 MG/100 ML, use 500 mg intravenously every eight hours until June 12, 2024, for a diagnosis of osteomyelitis (inflammation of the bone caused by infection), flush with 10cc NSS pre/post admin. To be administered by an RN only.
Review of Resident 72's Medication Administration Record (MAR) for May 3 through May 28, 2024, indicated that the resident was scheduled to receive Vancomycin at 0000 hours (12:00AM), 8:00 AM, and 1600 hours (4:00 PM). The MAR indicated that on May 11, 2024, the 1600 hours (4:00 PM) dose was not administered.
Review of nursing progress notes for May 11, 2024, revealed no documentation of the reason for the missed dose of Vancomycin nor was there any documentation to indicate the physician was notified of the missed dose.
Review of a facility-provided real-time administration detail report (a report that indicates the actual time the medication was administered) for administration of IV Vancomycin from May 3, 2024, through May 31, 2024, revealed that on the following dates Resident 72's IV Vancomycin medication was administered one hour or more beyond the physician prescribed time:
May 6, 2024 11:24 AM- 2 hours and 24 minutes overdue
May 8, 2024 11:07 AM - hours and 7 minutes overdue
May 8, 2024 6:18 PM - 1 hours and 18 minutes overdue
May 9, 2024 10:53 AM- 1 hour and 53 minutes overdue
May 12, 2024 10:25 AM- 1 hours and 25 minutes overdue
May 13, 2024 12:06 PM- 3 hours and 6 minutes overdue
May 21, 2024 10:33 AM-1 hours and 33 minutes overdue
May 21, 2024 7:51 PM- 2 hours and 51 minutes overdue
A physician order dated May 29, 2024, noted an order change to Vancomycin HCL (an antibiotic used to treat bacterial infections) Intravenous Solution 500 MG/100 ML, use 500 mg intravenously two times per day until June 19, 2024, for a diagnosis of osteomyelitis (inflammation of the bone caused by infection), flush with 10 cc NSS pre/post admin. To be administered by an RN only.
Review of Resident 72's Medication Administration Record (MAR) for May 29, through May 31, 2024, and June 1, 2024, through June 12, 2024, indicated that the resident was scheduled to receive Vancomycin at 9:00 AM and 21:00 hours (9:00 PM). The MAR indicated that on June 7, 2024, the 2100 hours (9:00 PM) dose was not administered.
Review of nursing progress notes for June 7, 2024, revealed no documentation of the reason for the missed dose of Vancomycin nor was there any documentation to indicate the physician was notified of the missed dose.
Interview with the Director of Nursing (DON) on June 13, 2024, at approximately 1:00 PM, failed to provide documented evidence that the facility timely administered 8 doses of the IV antibiotic therapy prescribed for Resident 72, and failed to notify the attending physician of two missed doses of the prescribed antibiotic.
28 Pa. Code 211.9(a)(1)(k) Pharmacy services
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing Services
28 Pa. Code 211.10 (a)(c)(d) Resident care policies
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected multiple residents
Based on a review of facility documents of QA meeting attendance and staff interview, it was determined that the facility failed to ensure that the Medical Director or designee attended quarterly Qual...
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Based on a review of facility documents of QA meeting attendance and staff interview, it was determined that the facility failed to ensure that the Medical Director or designee attended quarterly Quality Assurance Process Improvement (QAPI) Committee meetings for two of three quarters reviewed (August 2023 through June 2024).
Findings include:
A review of QAPI Committee meeting sign-in sheets for the period of August 2023 through June 2024, revealed that the Medical Director or other physician was not in attendance, virtually or in-person, at the QA meetings held from October 2023 through April 2024 missing 2 quarterly meetings (October 27, 2023, and December 5, 2023).
An interview with the Nursing Home Administrator (NHA) on June 14, 2024, at 9:00 AM, revealed that the facility was unable to provide documented evidence that the physician attended the facility's QAPI meetings on a quarterly basis as required.
28 Pa. Code 211.2 (d)(3)(4)(5)(6) Medical Director
28 Pa. Code 201.18 (e)(1)(3) Management
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
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, CDC (centers for disease control) infection control guidance, facility's infection contro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, CDC (centers for disease control) infection control guidance, facility's infection control policy and COVID-19 testing logs, and staff interview it was determined he facility failed to promptly implement infection control practices for cohorting like respiratory infections and testing for COVID-19 to prevent the spread of COVID-19 infections in the facility placing at least 12 residents (Residents 4, 6, 8, 10, 14, 16, 2, 20, 22, 24, 26 and 28) at increased risk for contracting COVID-19 and failed to implement effective interventions to prevent the spread of COVID-19 virus.
Findings include:
A review of the Pennsylvania Department of Health 2023-PAHAN-694-5-11-2023 update: Interim Infection Prevention and Control Recommendations for COVID-19 in healthcare settings dated May 11, 2023, revealed, this PA HAN (Pennsylvania Health alert Network) provides comprehensive information regarding infection prevention and control for COVID-19 in healthcare settings based on changes made by the Centers for Disease Control and Prevention (CDC) on May 8, 2023.
There was no facility specific COVID-19 policy's and procedures available to the survey team at the time of the survey. During an interview August 12, 2024 at 11:00 AM, the Nursing Home Administrator stated the facility follows CDC (Centers for Disease Control) guidelines and recommendations.
According to the COVID-19 Infection Control and Outbreak Response for Long-Term Care update as of February 2024 published by the Pennsylvania Department of Health;
If a resident develops signs and symptoms of COVID-19:·
Implement empiric transmission-based precautions while results are pending.
Do not place a person with suspected COVID-19 into a COVID-19 Care
Unit prior to confirmation of infection by positive test result
Identify a COVID-19 Care Unit Dedicated to Monitor and Care for Residents with Confirmed COVID-19
Dedicating an area within the facility to cohort residents on isolation for confirmed COVID-19 during their infectious period is best practice for decreasing the likelihood of transmission. Components of a COVID-19 Care Unit ideally include the following:
Physical separation from other rooms and spaces where residents are not
confirmed with COVID-19;
Single-person room(s) with designated bathroom(s);
Place a resident with suspected or confirmed COVID-19 in a single- person room.
The door should be kept closed, if safe to do so.
The resident should have a dedicated bathroom.
If limited single rooms are available, or if numerous residents are
simultaneously identified to have symptoms concerning for COVID-19,
residents may remain in their current location until cause of symptoms is
determined.
If cohorting, only residents with the same pathogen should be housed in
the same room. Multidrug-resistant organism (MDRO) colonization or
infection status, and/or presence of other communicable disease should
also be taken into consideration during the cohorting process.
Residents testing positive on July 18, 2024, and continued to reside with roommates who were COVID-19 negative during the quarantine period:
Resident 3, a COVID-19 positive resident, cohorted with Resident 4, who was COVID-19 negative, in room [ROOM NUMBER] bed 1 and 2, Cypress unit. Resident 4 tested positive on August 13, 2024, after cohorting with Resident 3,(COVID -19 positive).
Resident 5, a COVID-19 positive resident,cohorted with Resident 6 who was COVID-19 negative, in room [ROOM NUMBER] bed 1 and 2, Cypress unit Resident 6 tested positive on August 1, 2024, after cohorting with Resident 5, (COVID-19 positive).
Resident 7, a COVID-19 positive resident, cohorted with Resident 8, who was COVID-19 negative, in room [ROOM NUMBER] bed 1 and 2, Aspen unit. Resident 8 tested positive on July 25, 2024 after cohorting with Resident 7, (COVID-19 positive).
Resident 9, a COVID-19 positive resident, cohorted with Resident 10 who was COVID-19 negative, in room [ROOM NUMBER] bed 1 and 2, Aspen unit, Resident 10 tested positive on August 1, 2024 after cohorting with Resident 9, (COVID-19 positive).
Residents testing positive on July 25, 2024, continued to reside with roommates who were COVID-19 negative during the quarantine period:
Resident 13, a COVID-19 positive resident, cohorted with Resident 14, who was COVID-19 negative, in room [ROOM NUMBER] bed 1 and 2, Aspen unit.
Resident 15, a COVID-19 positive resident, cohorted with Resident 16 who was COVID -19 negative, in room [ROOM NUMBER] bed 1 and 2, Aspen unit.
Resident 17, a COVID-19 positive resident, cohorted with Resident 2, who was COVID-19 negative, in room [ROOM NUMBER] bed 1 and 2, Aspen unit.
Resident 19, a COVID-19 positive resident, cohorted with Resident 20, who was COVID-19 negative, in room [ROOM NUMBER] bed 1 and 2, Birch unit.
Resident 21, a COVID-19 positive resident, cohorted with Resident 22, who was COVID-19 negative, in room [ROOM NUMBER] bed 1 and 2, Birch unit.
Residents testing positive on August 1, 2024, and at the time of the survey beginning on August 12, 2024, continued to reside with roommates who were COVID-19 negative:
Resident 23, a COVID-19 positive resident, cohorted with Resident 24 who was COVID-19 negative, in room [ROOM NUMBER] bed 1 and 2 Aspen unit.
Resident 25, a COVID-19 positive resident, cohorted with Resident 26 who was COVID-19 negative, in room [ROOM NUMBER] bed 1 and 2 Aspen unit.
Testing logs were requested at the time of the survey ending August 12, 2024, to which the facility provided a sheet of paper entitled COVID Positive Residents testing dates were between July 18, 2024, and August 6, 2024. It could not be determined that all staff working on the affected second floor were COVID-19 tested as per CDC guidelines. No COVID-19 testing logs for staff were provided to the survey team during the survey.
The facility's infection control logs did not identify any signs or symptoms displayed by any of the residents or staff.
At the time of the survey, there was no documentation of any contact tracing for residents or staff.
There was no evidence at the time of the survey the facility followed their COVID-19 policy and CDC guidance for COVID-19 testing, contract tracing and cohorting residents positive or exposed to the COVID-19 virus.
During an interview July 26, 2024, at 9:00 AM, the Nursing Home Administrator and the Director of Nursing confirmed the facility did not move any of the COVID-19 positive residents, or their COVID-19 negative roommates on the second floor unit because they were under the assumption that cohorting COVID-19 positive residents was no longer recommended.
28 Pa Code 211.12 (c)(d)(1)(5) Nursing services
28 Pa. Code 211.10 (a)(c) Resident care policies
MINOR
(B)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and transfer notices, and staff interviews, it was determined that the facility failed to pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and transfer notices, and staff interviews, it was determined that the facility failed to provide written notices of facility-initiated transfers to the resident and the resident's representative for eight out of the 27 residents reviewed (Residents 7, 114, 101, 9, 63, 112, 2, and 106).
Findings include:
A clinical record review revealed that Resident 114 was transferred to the hospital on March 11, 2024, and returned to the facility on March 15, 2024.
A clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 114 and her resident representative regarding her transfer to the hospital on March 11, 2024, or as soon as practical.
A clinical record review revealed that Resident 7 was transferred to the hospital on June 8, 2024, and returned to the facility on June 10, 2024.
A clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 7 and her resident representative regarding her transfer to the hospital on June 8, 2024.
A clinical record review revealed that Resident 101 was transferred to the hospital on March 3, 2024, and returned March 15, 2024. The resident was again transferred to the hospital on March 30, 2024 and returned April 2, 2024.
Clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 101 and his resident representative regarding his transfer to the hospital on March 3 and March 30, 2024.
A clinical record review revealed that Resident 9 was transferred to the hospital on May 15, 2024, and returned to the facility on May 21, 2024.
A clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 9 and her resident representative regarding her transfer to the hospital on May 15, 2024.
A clinical record review revealed that Resident 63 was transferred to a community hospital on December 5, 2023, and returned December 7, 2023. The resident was again transferred to the hospital on January 5, 2024, and returned January 9, 2024.
Clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 63 and his resident representative regarding his transfer to the hospital on December 5, 2023, and January 5, 2024.
A clinical record review revealed that Resident 112 was transferred to the hospital on December 22, 2023, and returned December 28, 2023, on January 2, 2024, and returned January 4, 2024, February 19, 2024, and returned on February 27, 2024, March 6, 2024, and returned March 11, 2024, and on March 21, 2024, and returned on March 25, 2024. The resident was again transferred to the hospital on May 20, 2024, and returned May 24, 2024.
Clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 112 and his resident representative regarding his transfer to the hospital on December 22, 2023, January 2, 2024, February 19, 2024, March 6, 2024, March 21, 2024, and May 20, 2024.
A clinical record review revealed that Resident 2 was transferred to a community hospital on March 28, 2024, and readmitted to the facility as a new admission on [DATE], after a stay in a specialty hospital unit.
Clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 2 and his resident representative regarding his transfer to the hospital on March 28, 2024.
A clinical record review revealed that Resident 106 was transferred to the hospital on May 3, 2024, and readmitted to the facility on [DATE].
Clinical record review revealed no documented evidence that a notice of transfer or discharge letter was provided to Resident 106 and his resident representative regarding his transfer to the hospital on May 11, 2024.
During an interview on June 14, 2024, at approximately 11:30 AM, the Nursing Home Administrator and Director of Nursing confirmed that the facility had no documented evidence that Residents 7, 14, 101, 9, 63, 112, 2, and 106 and their representatives were provided written notices for the facility-initiated transfers.
28 Pa. Code 201.29 (a)(c.3)(2) Resident rights
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observations and staff interview, it was determined that the facility failed to post nurse staffing information on a daily basis to include the resident census and the total number and actual...
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Based on observations and staff interview, it was determined that the facility failed to post nurse staffing information on a daily basis to include the resident census and the total number and actual hours worked by licensed and unlicensed staff.
Findings Include:
Observations in the facility lobby on June 11, 2024, at 8:45 AM and 3:10 PM, and June 12, 2024, at 9:00 AM revealed that the facility's nurse staffing information was not posted in the facility's designated area.
An interview with the Director of Nursing on June 12, 2024, at 9:10 AM revealed that the nurse staffing information should be posted daily at the beginning of each shift in a prominent location.
28 Pa. Code 201.14 (a) Responsibility of licensee
Apr 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 F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the baseline care plan failed to fully address the re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the baseline care plan failed to fully address the resident's immediate individual needs for care and services upon admission of one of 22 residents sampled (Resident 111).
Findings:
A review of Resident 111's clinical record revealed that she was admitted to the facility on [DATE], with above of the knee amputations of the left and right legs.
Review of the Resident 111's baseline care plan, conducted at the time of the survey ending April 12, 2024, revealed that the resident's baseline care plan did not identify the resident's bilateral above the knee amputations and resident's needs for assistance with activities of daily living as a result of the amputations, present upon admission.
The resident's baseline care plan, initiated April 3, 2024, revealed that the resident was at risk for falls related to gait/balance problems with planned interventions of to be sure my call light is within reach and encourage me to use it for assistance as needed, and to ensure that I am wearing appropriate footwear when ambulating or mobilizing in wheelchair.
The resident's baseline care plan failed to identify interventions to address her current needs related to the bilateral amputation of the legs present at the time of admission.
Interview with the Director of Nursing on April 12, 2024, at approximately 1:55 PM confirmed that the facility failed to ensure that the resident's baseline care plan included the minimum healthcare information necessary to properly care for Resident 111 immediately upon admission, which would address resident-specific concerns related to bilateral amputations.
28 Pa. Code 211.12(d)(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
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
Based on review of select facility policy and grievances lodged with the facility and staff interviews it was determined that the facility failed to put forth timely and sufficient efforts to promptly...
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Based on review of select facility policy and grievances lodged with the facility and staff interviews it was determined that the facility failed to put forth timely and sufficient efforts to promptly resolve grievances for two residents out of 22 sampled. (Resident CR1 and 11)
Findings include:
Review of the facility's Grievance policy and procedure provided by the facility during the survey on April 12, 2024, indicated that residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Upon receipt of a grievance and/or complaint, the grievance officer with review and investigate the allegations and submit a written report of such findings to the administrator. The grievance office, administrator and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. The administrator will review the findings with grievance officer to determine what corrective actions, if any, need to be taken. The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed of the findings of the investigation and the actions that will be taken to correct any identified problems.
Review of grievance submitted by Resident 11 dated February 9, 2024, revealed that the resident expressed concerns related to a neighboring resident's disruptive and threatening behaviors. Resident 11 further stated that the resident's behaviors start as early as 5 AM and into the evening. Resident 11 expressed that his behavior is tolerated, and feedback is it doesn't work anyway [behavior interventions].
Review of grievance submitted by Resident 11 dated February 14, 2024, and the notes from the Resident Council meeting conducted on February 20, 2024, revealed that Resident 11 continued to have concerns with a neighboring resident's behaviors. Resident 11 stated that the neighboring resident has gotten violent, screaming at everyone, pounding on the walls, he follows people around screaming.
A review of the facility's resolution to Resident 11's complaint, revealed that the facility staff did not discuss Resident 11's grievance until February 14, 2024, 5 days after the resident submitted the grievance regarding disruptive behavior displayed by another resident, and not until Resident 11 submitted another grievance on that date regarding the same resident's behaviors.
There was no evidence that the resident's concerns/grievance was communicated to the necessary departments for timely response and/or resolution as noted in facility policy.
Review of grievance submitted by family of Resident CR1, on the resident's behalf, dated February 25, 2024, revealed that the resident's glasses, that she wears daily, were missing. According to summary of findings or conclusion of the grievance, the resident's glasses had been missing since February 23, 2024, and later found on March 5, 2024. Resident CR1's glasses were missing for 12 days without evidence of facility efforts to find the resident's glasses that she wears daily or resolve concern that the resident was without her glasses.
There was no evidence that the concern expressed by Resident CR1's family was promptly communicated to the necessary departments for timely response and/or resolution.
During an interview with the Nursing Home Administrator (NHA) on April 12, 2024, at approximately 2 PM. the NHA confirmed that there was no documented evidence that the facility had timely initiated sufficient efforts to resolve the residents and their families complaints.
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 201.29 (a) Resident Rights
Feb 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and incident reports, resident and staff interviews it was determined that the facility fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and incident reports, resident and staff interviews it was determined that the facility failed to consistently provide care and services, consistent with professional standards of practice, to prevent the development of pressure ulcers for one resident out of four sampled residents (Resident 110).
Findings:
According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.
The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.
A review of Resident 110's clinical record revealed she was most recently admitted to the facility on [DATE], with diagnoses including diabetes, muscle wasting, chronic kidney disease, and peripheral vascular disease (PVD).
Resident 110's care plan dated December 17, 2023, indicated that the resident was at risk for skin integrity breakdown due to diagnosis of diabetes, venous insufficiency, vitamin deficiency, bilateral lower extremity edema, with a history of diabetic foot ulcer of her right ankle. The stated goal is that she be free from pressure injuries through the next review, and identify risks, with a target date of April 25, 2024. Planned interventions were to elevate the resident's bilateral lower extremities and heels, on 2-3 pillows while at rest, apply moisturizing lotion in the morning and in the evening with care, moisturizer cream to bilateral feet daily, inspect skin daily with care and bathing, and report any changes, keep bed linen clean, dry, and free of wrinkles, keep skin clean and dry, maintain adequate nutrition and hydration. Encourage resident to frequently shift weight, initiated, February 2, 2024.
The resident's care plan noted actual impairment to skin integrity of the lateral foot, an intact blister, related to edema dated October 9, 2023.
A nurses note dated December 25, 2023, 11:20 AM, revealed that a blister like area was noted on the fifth toe of the resident's right foot. Minimal pain noted per resident, supervisor informed and in to assess area. Betadine was applied. Certified Registered Nurse Practitioner (CRNP) was consulted, will see the resident tomorrow. The entry noted that the resident had the same area in the past, and that nursing will continue to monitor.
A skin and wound note dated December 26, 2023, 4:11 PM revealed right lateral foot, stage 2, measuring 2 centimeter (cm) x 1 cm x 0 cm, blister (nonthermal), right foot. Recommendations were to cleanse the area with normal saline, apply skin prep to base of the wound, leave open to air, change daily. Preventative measure off loading of affected area, repositioning according to assessed needs, follow up in 1 week.
A nurses note dated December 27, 2023, 10:11 PM while providing wound care to resident's right foot, nursing noted edema to the resident's bilateral lower extremities. Nursing notified the CRNP, and a new order was received to increase the resident's Lasix 40 mg daily (a diuretic medication to remove excess fluid from the body), which had been decreased to 20 mg on December 15, 2023.
A nurses note dated January 2, 2024, 12:45 PM indicated that a Physical Therapy (PT) evaluation was ordered related to the new pressure injury to the resident's right foot. A Multidisciplinary Therapy Screen dated January 3, 2024, indicated that the resident was independent with transfers, bed mobility, and ability to move both lower extremities. Resident reported that she doesn't utilize shoes. The resident stated that while in bed, she lays on her left side with her right foot elevated. Physical Therapy intervention was not required secondary to the resident being independent.
A skin/wound note dated January 22, 2024, 12:09 PM, indicated that the area on the right lateral foot was resolved and treatment discontinued.
A review of a skin and wound note dated February 1, 2024, at 10:14 PM, indicated that the resident informed nursing that the area on her foot was hurting. Upon assessment, an intact blood blister noted to right lateral foot by 5th toe, area is reoccurring. CRNP will be in to see resident. Betadine and dry dressing daily until seen by wound care. Resident aware. Resident rests her foot on stand of bedside table throughout the day while sitting and completing puzzles. Resident 110 is in chair for most of day. Resident has been educated several times by nursing that she needs to reposition that foot throughout the day to which she verbalizes understanding. Will continue to monitor site and encourage resident to reposition her foot while in chair. CRNP aware of above.
During interview with Resident 110 on February 7, 2024, at approximately 11:50 AM, the resident's feet were observed resting directly on the metal frame of her bedside table, which was positioned in front of her. The resident was wearing non-skid socks, with her right foot pressed against the bare metal of the bedside table frame. The resident stated that she spends many hours every day in her chair. She stated there are only so many places to put her feet, while sitting in a chair, and with the bedside table in front, it is a challenge not to have her feet above, below, or resting on the beside the frame. Resident 110 stated that staff is well aware that she does not wear shoes.
Interview with Employee 1, Physical Therapist Therapy Director, on February 7, 2024, at approximately 1:05PM, confirmed the above screen and that the resident was known to not wear shoes. She further indicated that if the resident was to wear shoes, this could most certainly contribute to a blister, along with the potential for skin damage if the resident wore only socks, and pressure was applied to the resident's feet against a metal frame.
The facility was aware of the resident's risk factors for skin breakdown and recurrent pressure sore to the resident's foot, along with the resident's habit of not wearing shoes. The facility failed to develop and implement individualized approaches to address this risk/contributing factor to prevent pressure sore development.
Interview with the Director of Nursing (DON) on February 7, 2024, at approximately 1:30 P.M., confirmed that the facility failed to demonstrate the implementation of timely and adequate measures necessary to prevent the development of a reoccurring right foot pressure area.
28 Pa. Code 211.12 (d)(3)(5) Nursing services.
Nov 2023
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records and medication error report and staff interview it was revealed that the facility f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident clinical records and medication error report and staff interview it was revealed that the facility failed assure that one of three residents reviewed was free of significant medication errors (Resident 23).
Findings include:
The Principles of Medication Administration, The Five Rights of Medication Administration indicate that when you are giving medication, regardless of the type of medication, you must always follow the five rights.
Each time you administer a medication, you need to be sure to have the:
1. Right individual
2. Right medication
3. Right dose
4. Right time
5. Right route
According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following: The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice.
A review of the clinical record revealed that Resident 23 was admitted to the facility on [DATE], with diagnoses of dementia, protein - calorie malnutrition, falls with fracture, and congestive heart failure (CHF).
A quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 11, 2023, revealed that the resident was severely cognitively impaired with a BIMS score of 0 (Brief Interview for Mental Status a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 0-7 equates to being severely cognitively impaired).
A review of a general note, dated October 27, 2023, at 2:21 PM, revealed that an LPN administered Resident 23's the following medications that morning: Norvasc 5 mg (medication used to treat high blood pressure), Hydroxyzine 25 mg (medication used to treat itching caused by allergies), Ativan 0.5mg (medication used to treat anxiety), and Flomax 0.4 mg (medication used to treat enlarged prostate).
Te Certified Registered Nurse Practitioner (CRNP) was made aware with new orders to hold the resident's scheduled routine morning, AM medications, and to obtain vital signs every (Q) shift x 72 hours.
A review of facility provided document entitled Medication or Drug Incident Report dated, October 27, 2023, indicated at 7:50 AM, Employee 1, LPN, administered the medications that were not prescribed for Resident 23 that morning, including Norvasc, Hydroxyzine, Ativan, and Flomax, which were intended for administration to Resident 10. Employee 1, LPN, had asked Employee 2, a nurse aide, which resident was sitting in hall in the chair, and the aide reportedly stated, Resident 10. The action taken by the facility included a review of the event with responsible nurse, Employee 1 (LPN).
During an interview with the Director of Nursing (DON) on November 7, 2023, at approximately 2 P.M., confirmed that Resident 23 received multiple medications which she was not prescribed on the morning of October 27, 2023, resulting in a significant medication error.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
Based on observation and resident and staff interviews, it was determined that the facility failed to reasonably accommodate residents' need for call bell accessibility for 5 out of 7 residents sample...
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Based on observation and resident and staff interviews, it was determined that the facility failed to reasonably accommodate residents' need for call bell accessibility for 5 out of 7 residents sampled (Residents 86, 89, 111, 118, and 119).
Findings include:
Observation on November 7, 2023, at 10:35AM revealed Resident 111 seated in a wheelchair along the left side of her bed. The resident's call bell was observed tucked under the mattress on the right side of her bed, out of sight and reach of the resident.
During an interview at the time of the observation, Resident 111 stated that she was unable to locate her call bell to request staff assistance when needed.
An interview with Employee 3 (RN nurse consultant) on November 7, 2023, at 10:40 AM confirmed the observation that Resident 111 did not have access to a call bell to summon staff assistance.
Observation on November 7, 2023, at 10:45 AM revealed that Resident 119 was lying in bed unable to reach or access her call bell. The resident's call bell was wrapped around the bed frame and out of reach of Resident 119.
Observation on November 7, 2023, at 10:47 AM revealed that Resident 118 was lying in bed unable to reach her call bell. The resident's call bell was observed on the floor.
An interview with Employee 4 (licensed practical nurse) on November 7, 2023, at 10:50 AM confirmed the observations that Residents 119 and 118 did not have access to a call bell to summon staff assistance when needed.
Observation on November 7, 2023, at 11:00 AM revealed Resident 86 lying in bed unable to reach her call bell. The resident's call bell was observed on the floor.
Observation on November 7, 2023, at 11:05 AM revealed Resident 89 lying in bed unable to reach her call bell. The resident's call bell was observed lodged under the wheel of the bed frame
An interview with Employee 5 (licensed practical nurse) on November 7, 2023, at 11:10 AM confirmed the observations that Residents 86 and 89 did not have access to a call bell to summon staff assistance when needed.
An interview with the Director of Nursing on November 7, 2023, at approximately 3:30 PM verified that call bells are to be placed within reach of each resident at all times.
28 Pa. Code 211.12 (d)(5) Nursing Services
28 Pa. Code 201.29 (a) Resident Rights
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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select investigative reports and facility policy, and resident and staff interviews, it w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, select investigative reports and facility policy, and resident and staff interviews, it was determined that the facility failed to consistently implement sufficient measures to protect three residents (Residents 45, 55, and 82) out of 18 sampled from physical abuse perpetrated by other residents.
Findings included:
A review of the current facility policy titled Abuse Prevention Program, dated as revised in December 2016, revealed that it is the facility's policy that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy indicated that as part of resident abuse prevention, the administration will protect residents from abuse by anyone, including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.
A clinical record review revealed that Resident 18 was admitted to the facility on [DATE], with diagnoses that included dementia (a condition characterized by the loss of cognitive functioning such as thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities).
A review of a comprehensive Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care), dated October 14, 2023, revealed that Resident 18 was severely cognitively impaired, displayed physical behaviors directed towards others such as kicking, hitting, pushing, or scratching on 1-3 days during the assessment look-back period and verbal behaviors directed toward others such as threatening, screaming, or cursing on 1-3 days during the assessment look-back period.
The resident's care plan identified Resident 18 as having the potential to demonstrate physical behaviors with dementia and poor impulse control with planned interventions implemented on June 21, 2022, for assessing and addressing contributing sensory deficits, assessing and anticipating resident needs, providing physical and verbal cues to alleviate anxiety, giving the resident as many choices as possible about care and activities, monitoring, documenting, and reporting to the physician of danger to himself and others, providing psychiatric consultation as needed, intervening before the resident becomes agitated, guiding the resident away from the source of distress, and if the resident's response is aggressive, staff to walk calmly away and approach later.
Resident 18's plan of care was updated on September 14, 2023, to implement diversional activities such as counting money and filling out accountant ledgers and to provide gentle redirection as needed.
A nursing progress note dated August 15, 2023, at 3:53 PM, indicated that Resident 18 had increased behaviors, including punching staff and being verbally and physically aggressive.
A nursing progress note dated August 17, 2023, at 1:49 PM indicated that Resident 18 was agitated when redirected, pacing the hallway and entering and exiting other rooms despite redirection.
A nursing progress note dated August 23, 2023, at 4:51 PM indicated that Resident 18 went into another resident's room. Staff asked him to leave, and he became aggressive and kicked the staff.
A nursing progress note dated August 25, 2023, at 10:48 PM indicated that Resident 18 was experiencing an episode of increased behaviors and was unable to be redirected. Nursing noted that the resident was attempting to physically assault staff and residents.
A facility investigation report dated September 10, 2023, at 3:45 PM revealed that Employee 6, RN, was called to Resident 82's room. Employee 6 reported that when she entered the room, Resident 82 stated, I was just in here watching television when he {Resident 18} came in and started pushing my table away. I asked him to leave, and that's when he pushed all my stuff off my table, and my cookies and stuff fell on the floor. He hit me in the chest and stomach with his fists closed. He didn't hit me hard. I think he was trying to scare me.
The facility investigation included a statement dated September 10, 2023, at 3:45 PM, from Employee 7, a nurse aide, which indicated that the employee was providing care to another resident when she heard Resident 82 screaming. She went to check on him and found Resident 18 standing by the window in Resident 82's room. Resident 82 reported that Resident 18 hit him in the chest and stomach. Employee 7 indicated that Resident 82's personal stuff was all over the floor and that she assisted Resident 18 out of Resident 82's room and then notified the nurse.
A statement dated September 10, 2023, provided by Employee 8, LPN, (no time documented), revealed that a nurse aide called Employee 8 to Resident 82's room. Employee 8 indicated that Resident 82 reported that Resident 18 came into his room and hit him in the stomach and chest. Resident 18 was removed from the room, and the registered nurse supervisor was notified.
A nursing progress note dated September 10, 2023, at 4 PM revealed Employee 6, RN, took Resident 82's vital signs and assessed his skin with no noted changes in skin integrity, bruising, or redden areas. The report indicated that Resident 82's representative and physician were informed about the incident and local police were notified.
A nursing progress note dated September 10, 2023, at 6:02 PM revealed Employee 6 observed Resident 18 in the hallway talking to himself in a mad, aggressive tone with hands clenched at his sides. Employee 6 indicated that Resident 18 was unable to give a description of the incident with Resident 82.
A clinical record review revealed that Resident 82 was admitted to the facility on [DATE], with diagnoses to include lymphocytic leukemia (a type of cancer in which the bone marrow makes too many white blood cells) and chronic obstructive pulmonary disease (COPD). A review of a quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 82 had mild cognitive impairment with a BIMS score of 11 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 8-12 indicates mild cognitive impairment).
During an interview on November 7, 2023, at 2:05 PM, Resident 82 stated that a while back, Resident 18 came into his room and punched him in the stomach and in the chest. Resident 82 explained that Resident 18 started to go through his things, and when he asked Resident 18 to leave, that's when Resident 18 punched him. Resident 82 stated that he was worried about Resident 18 coming in his room again, but feels better because he hasn't seen Resident 18 recently.
A review of a facility investigation report revealed a witness statement provided by Resident 45's family member dated September 21, 2023, at 2:39 PM. The family member indicated that she was visiting Resident 45 in her room when Resident 18 entered. Resident 45 told Resident 18 to get out of her room. Resident 18 proceeded to hit Resident 45 in the base of her neck and temple and then twist her right wrist. The statement indicated that Resident 45's family member yelled for help.
A witness statement provided by Employee 9, LPN, on September 21, 2023, at 2:39 PM indicated that Employee 9 was charting when she heard a female yell. Employee 9 stated that she ran down the hall to Resident 45's room. Resident 45 stated that Resident 18 hit her. Employee 9 indicated that a nurse aide, escorted Resident 18 out of Resident 45's room. Employee 9 reported that Resident 45's vitals were taken, and she was assessed with noted redness and bruising to her right temple and with red marks on her right shoulder. Her statement also indicated that the Director of Nursing and Nurse Supervisor were made aware.
A witness statement dated September 21, 2023, at 2:39 PM provided by Employee 10, a nurse aide, indicated that Employee 10 was passing ice to residents when she heard a resident yelling for help. The statement indicated that Employee 10 entered Resident 45's room, and Resident 18 was standing near Resident 45 and yelling at her. Employee 10 indicated that Resident 45 stated that Resident 18 hit her. Employee 10 reported that she assisted Resident 18 out of the room.
A nursing progress note dated September 21, 2023, at 3:01 PM indicated that Resident 45 had bruising on the right side of her head and reports pain in her right back radiating to her arm. The entry indicated that the physician's certified registered nurse practitioner was notified and that the resident was going to the hospital emergency department for further evaluation.
A nursing progress note dated September 22, 2023, at 11:17 AM indicated that Resident 45 returned from the ER with head throbbing, no acute injuries, and no changes to skin integrity.
A clinical record review revealed that Resident 45 was admitted to the facility on [DATE] with a diagnosis that included left-side hemiplegia and hemiparesis following cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain, resulting in impairment to one side of the body). A review of a quarterly Minimum Data Set assessment dated [DATE] revealed that Resident 45 was cognitively intact with a BIMS score of 15.
During an interview on November 7, 2023, at 14:15 PM, Resident 45 stated that Resident 18 came into her room while her family member was visiting a few weeks ago. She stated that she told Resident 18 to get out of her room, and then he punched her in the side of her head and in the back and twisted her wrist. Resident 45 stated that following the incident, she felt nervous and had trouble sleeping at night. She said she wasn't herself for a while but is feeling better now.
A clinical record review revealed that Resident 55 was admitted to the facility on [DATE], with a diagnosis that included intermittent explosive disorder (a mental health disorder characterized by recurrent behavioral outbursts) and thrombocythemia (a disease in which the body produces too many platelets that could lead to a variety of potentially life-threatening complications). A review of a quarterly Minimum Data Set assessment dated [DATE] revealed that Resident 55 was moderately cognitively impaired with a BIMS score of 10.
Resident 55's plan of care dated June 14, 2022, noted that Resident 55 had the potential to demonstrate verbally and physically abusive behaviors related to cognition, ineffective coping skills, poor impulse control, and difficulty communicating. Planned interventions included analyzing times, places, circumstances, triggers, and de-escalation behaviors; documenting, assessing, and anticipating residents' needs (hunger, thirst, toileting); assessing residents' coping skills and support systems; assessing residents' understanding of the situation; allowing time for the resident to express himself and his feelings towards the situation; offering alternative activities; offer residents a cup of coffee, provide praise for gardening efforts, and psychiatric or psychogeriatric consultation as indicated when the resident becomes agitated. intervene before agitation escalates, guide away from the source of distress, and engage calmly in conversation.
A nursing progress note dated August 14, 2023, at 12:53 PM indicated that Resident 55 came out of his room, slammed his bedroom door, cursed, and stated he was not going to wear name bands distributed to residents.
A nursing progress note dated September 15, 2023, at 9:17 AM indicated that Resident 55 kicked a food cart drawer closed on a nurse aide's fingers while she attempted to remove a food tray. The note indicated that Resident 55 yelled, Good for you, you f**cking c*nt.
A review of a facility investigative report and nursing progress note dated September 26, 2023, at 1:39 PM, indicated that Employee 12, activities director, heard a man screaming loudly and a woman coming from the social room. Resident 45 and Resident 55 were observed yelling at each other. Employee 12 indicated that both residents continued to yell at each other. The documentation indicated staff separated the residents, and an incident report was given to the Director of Nursing.
A review of a facility investigative report and document completed by Employee 11, Social services, on September 28, 2023, at 3:20 PM indicated that the incident between Resident 45 and Resident 55 was not witnessed, and local police were notified following the resident-to-resident abuse.
A review of a facility investigative report revealed a witness statement dated September 26, 2023, at 11:20 AM, provided by Resident 45. The statement indicated that Resident 45 was in the social room as Resident 55 passed without saying anything. Resident 45 told Resident 55 to mind his own business. Resident 55 responded by wheeling towards Resident 45, calling her a prick, and raising his fist at her. Resident 45 kicked Resident 55 in his leg, then Resident 55 kicked Resident 45 in her leg. Resident 45 and Resident 55 became verbally loud until staff came into the room and separated them.
A review of a facility investigative report revealed a witness statement provided by Resident 55 dated September 26, 2023, at 11:30 AM indicated that Resident 45 was in the TV room watching a game show. Resident 55 indicated that Resident 45 snapped and started yelling at him. He stated that she kicked at him, striking him once in the left knee and once, just grazing his left calf area. Resident 55 denied having any interaction to precipitate her outburst. The statement indicated that Resident 55 declined to allow anyone to assess or evaluate him for injury. The statement indicated that Resident 55 met with Social Services, was provided an opportunity to vent his anger, was calmer after the intervention, and was provided encouragement.
During an interview on November 7, 2023, at approximately 15:00 PM, the Director of Nursing (DON) was unable to provide evidence that the facility implemented effective interventions to prevent resident to resident abuse.
28 Pa. Code 201.14(a) Responsibility of Licensee
28 Pa. Code 201.18(e)(1) Management
28 Pa. Code 201.29(a) Resident rights
28 Pa. Code 211.12(d)(5) Nursing Services
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0745
(Tag F0745)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility investigative reports, and resident and staff interviews, it was determined that...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records, facility investigative reports, and resident and staff interviews, it was determined that the facility failed to provide therapeutic social services to assess the psychosocial status and needs of residents following incidents of abuse perpetrated by other residents to promote the psychosocial well-being of two of 18 residents sampled (Resident 45 and 82).
Findings include:
A clinical record review revealed that Resident 82 was admitted to the facility on [DATE], with diagnoses to include lymphocytic leukemia (a type of cancer in which the bone marrow makes too many white blood cells) and chronic obstructive pulmonary disease (COPD).
A review of a quarterly Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 11, 2023, revealed that Resident 82 was moderately cognitively impaired with a BIMS score of 11 (Brief Interview for Mental Status- a tool to assess cognitive function; a score of 8-12 indicates moderate cognitive impairment).
A facility investigative report dated September 10, 2023, revealed that Employee 6, RN was called to Resident 82's room. Employee 6 entered the room, and Resident 82 stated, I was just in here watching television when he {Resident 18} came in and started pushing my table away. I asked him to leave, and that's when he pushed all my stuff off my table, and my cookies and stuff fell on the floor. He hit me in the chest and stomach with his fists closed. He didn't hit me hard. I think he was trying to scare me.
During an interview on November 7, 2023, at 2:05 PM, Resident 82 stated that a while back, Resident 18 came into his room and punched him in the stomach and in the chest. Resident 82 explained that Resident 18 started to go through his things, and when he asked Resident 18 to leave, that's when Resident 18 punch him. Resident 82 stated that he was worried about Resident 18 coming back into his room, but that he hasn't seen him in a while, and that has made him feel better.
There was no documented evidence that Resident 82's psychosocial status and needs were assessed following the incident of physical abuse perpetrated by Resident 18 and emotional support offered to Resident 82 to promote the resident's mental well-being.
During an interview on November 7, 2023, at approximately 15:00 PM, the Director of Nursing (DON) was unable to provide evidence that Resident 82's psychosocial status was assessed and the resident provided emotional support following the incident of physical abuse by Resident 18.
A clinical record review revealed that Resident 45 was admitted to the facility on [DATE] with a diagnosis that included left-side hemiplegia and hemiparesis following cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain, resulting in impairment to one side of the body).
A review of a quarterly Minimum Data Set assessment dated [DATE] revealed that Resident 45 is cognitively intact with a BIMS score of 15.
A clinical record review revealed that Resident 55 was admitted to the facility on [DATE], with a diagnosis that included intermittent explosive disorder (a mental health disorder characterized by recurrent behavioral outbursts) and thrombocythemia (a disease in which the body produces too many platelets that could lead to a variety of potentially life-threatening complications).
A review of a quarterly Minimum Data Set assessment dated [DATE], revealed that Resident 55 was moderately cognitively impaired with a BIMS score of 10.
A review of a facility investigative report and nursing progress note dated September 26, 2023, at 1:39 PM, indicated that Employee 12, activities director, heard a man loudly screaming and a woman coming from the social room. Resident 45 and Resident 55 were observed yelling at each other. Employee 12 indicated that both residents continued to yell at each other while staff was questioning them.
A review of a facility investigative report completed by Employee 11, social services, on September 28, 2023, at 3:20 PM indicated that the incident between Resident 45 and Resident 55 was not witnessed, and local police were notified.
A review of a facility investigative report revealed a witness statement dated September 26, 2023, at 11:20 AM, provided by Resident 45. Resident 45 stated that she was in a social room as Resident 55 passed without saying anything. The statement indicated that Resident 45 told Resident 55 to mind his own business. Resident 55 responded by wheeling towards Resident 45, calling her a prick, and raising his fist at her. Resident 45 kicked Resident 55 in his leg, then Resident 55 kicked Resident 45 in her leg. Resident 45 and Resident 55 became verbally loud until staff came into the room and separated them.
A witness statement provided by Resident 55 dated September 26, 2023, at 11:30 AM indicated that Resident 45 was in the TV room watching a game show. Resident 55 indicated that Resident 45 snapped and started yelling at him. He stated that she kicked at him, striking him once in the left knee and once, just grazing his left calf area. Resident 55 denied having any interaction to precipitate her outburst.
There was no documented evidence that Resident 45's psychosocial status and needs were assessed following the physical abusive event with Resident 55 on September 26, 2023,and emotional support offered to Resident 45's mental well-being.
During an interview on November 7, 2023, at approximately 15:00 PM, the Director of Nursing (DON) confirmed that there was no documented evidence of social service assessment of psychosocial status and needs and provision of social service interventions provided to Residents 45 and 82 following episodes of physical abuse perpetrated by other residents.
28 Pa. Code 201.29 (a) Resident rights.
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
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on review of clinical records and controlled substance count records, resident and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accoun...
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Based on review of clinical records and controlled substance count records, resident and staff interviews, it was determined that the facility failed to implement procedures to promote accurate accounting and administration of controlled drugs for one of three residents sampled (Resident 57).
Findings include:
A review of Resident 57's clinical record revealed admission to the facility on September 20, 2023, with diagnoses of gastro-esophageal reflux disease (GERD), depression, chronic obstructive pulmonary disease (COPD), protein-calorie malnutrition, and diabetes.
An admission Minimum Data Set assessment (MDS - a federally mandated standardized assessment process conducted periodically to plan resident care) dated September 24, 2023, revealed that the resident was moderately impaired with a BIMS (brief interview to assess cognitive status) score of 12 (a score of 8-12 indicates moderate impairment).
The resident had a physician order dated September 29, 2023, for Adderall oral tablet 10 milligram (mg), give 2 tablets by mouth two times a day for attention deficit related to narcolepsy.
During an interview with Resident 57, on November 7, 2023, at approximately 11:44 AM, the resident complained of not receiving her evening-night medications on October 28, 2023. The resident stated that she had informed staff of her complaint.
A review of the resident's October 2023, Medication Administration Record (MAR), revealed that nursing documented the administration of Adderall 10 mgs (2 tablets) at both 8:00 AM, and 8:00 PM (2000 hrs), on October 28, 2023.
Resident 57's controlled drug record accounting for Adderall 10 mg, give 2 tablets (20 mg) by mouth two times a day for attention deficit. The record indicated that on October 27, 2023, Adderall 10 mg, 2 tablets, was administered at 8:00 AM, and 7:00 PM., (31 doses remaining), October 28, 2023, Adderall 10 mg, 2 tablets, was administered at 8:00 AM, (30 doses present), and on October 29, 2023, Adderall 10 mg, 2 tablets, was administered at 9:00 AM, (29 doses present).
Resident 57's controlled drug record revealed evidence of only one administration to the resident on October 28, 2023, at 8:00 AM, and not the second administration at 8:00 PM (2000 hrs), as physician ordered and nursing documented on the resident's MAR.
Facility failed to identify the discrepancy noted between the resident's controlled substance sheet and MAR and failed to implement procedures to promote accurate administration, and accounting of controlled substance medication, to deter the potential drug diversion.
Interview with the Director of Nursing (DON), on November 7, 2023, at approximately 3:55 PM, indicated that her expectation is that the controlled substance records and medication administration records be accurately documented.
28 Pa. Code 211.19(a)(1)(k) Pharmacy services
28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 211.12 (d)(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
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on review of the facility's plan of correction from the surveys of September 28, 2023 and November 7, 2023, and the findings of the survey ending December 7, 2023, it was determined that the fac...
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Based on review of the facility's plan of correction from the surveys of September 28, 2023 and November 7, 2023, and the findings of the survey ending December 7, 2023, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to develop and implement corrective action plans to prevent continued quality deficiencies related to abuse prevention and pharmacy services and to ensure that plans designed to improve the delivery of care and services were consistently implemented to effectively deter future quality deficiencies.
Findings include:
The facility's deficiencies and plan of correction for the survey ending November 7, 2023, revealed the facility developed a plan of correction that included quality assurance monitoring systems to ensure that solutions were sustained. The results of the current survey ending December 7, 2023, revealed that two residents, Resident 1 and 2 were physically abused by Resident 3 and continued to deficient practice was identified in abuse.
In response to the deficiency cited under resident abuse during the survey of November 7, 2023, the facility's plan of correction revealed that the plan included DON (director of nursing) or designee will review incident reports for resident abuse to ensure effective interventions are in place to prevent resident abuse. Audits will be reviewed by the QAPI committee who will determine the need for further audits.
However, at the time of the revisit survey ending December 7, 2023, review of clinical records revealed Resident 3 had physically abused Resident 1 on November 23, 2023. Further review revealed the facility failed to implement new effective interventions in response to Resident 3's physical aggression and abuse of Resident 1. Resident 3 then physically abused Resident 2 on November 25, 2023. The facility's quality assurance monitoring plan failed to identify this ongoing deficient practice.
The facility's QAPI committee failed to identify that the facility had failed to implement their plan of correction, in a manner consistent with the regulatory guidelines for the deficiency cited, to ensure that solutions to the problem of resident abuse were sustained.
During the survey ending September 28, 2023, deficient facility practice was identified under the requirement of pharmacy procedures whereas the facility failed to implement procedures to promote accurate controlled medication records on two of two medication carts observed.
The facility's plan of correction indicated the following steps to correct the quality deficiency and sustain correction:
1.
Verification of narcotic count sheets are completed at the end of each shift
2.
An audit of last week of narcotic signature sheets will be completed to validate 2 nurses are signing at shift change
3.
Education will be completed with the facility RN's and LPN's on Controlled substance policy by staff development coordinator. DON or designee will review narcotic count sheets to ensure controlled substance sheets are complete.
4. An audit will be completed daily for 5 days, weekly for 3 weeks;
then monthly for 2 months of 3
random units narcotic count
sheets to validate there were 2
nurse signatures at change of
shift. Results will be reviewed
with the Quality Assurance
Performance Committee
This corrective action plan was to be in place by October 17, 2023. However, at the time of this revisit survey a review of controlled drug shift count records and select facility policy and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled medication records on two of two medication carts observed.
The facility's quality assurance plan failed to identify continued non-compliance and sustain solutions to the identified quality deficiency in pharmacy services
Refer F600 and F755
28 Pa. Code 211.12(c) Nursing services
28 Pa. Code 201.18(e)(1) Management.
Sept 2023
12 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to timely notify the residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to timely notify the resident's interested representative of a change in condition for one resident out of 21 sampled (Resident CR1).
Findings include:
A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus, left hallux (big toe) amputation, partial first metatarsal ray resection of left foot (procedure used to help salvage the foot and maintain bipedal ambulation), and a right foot ulcer.
A review of a nurses note dated September 11, 2023, noted resident with fluid filled blisters to bilateral shins approximately the size of a large grape and noting that the physician was aware. New orders were received and updated accordingly. The order was for Furosemide (a diuretic medication) to be given twice daily for three days. Antibiotic cream and dry sterile dressing to be put in place once sites open and begin draining.
There was no documented evidence that the resident's resident representative was informed of the presence of the fluid filled blisters and need for a change in treatment as of the time of review on September 28, 2023
An interview with the director of nursing on September 28, 2023, at approximately 2:00 PM confirmed the facility failed to notify the resident's representative in a timely manner of the fluid filled blisters on the resident's shins.
28 Pa Code 211.12 (c)(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 F0661
(Tag F0661)
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 complete a discharge summary,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to complete a discharge summary, which included a recapitulation of the resident's stay, the course of illness, corresponding treatment, discharge instructions, and a post-discharge care plan for one of one discharged resident record reviewed (Resident CR1).
Findings include:
A review of the closed clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses including diabetes mellitus, left hallux (big toe) amputation, partial first metatarsal ray resection of left foot (procedure used to help salvage the foot and maintain bipedal ambulation), and right foot ulcer.
A closed clinical records review, conducted on September 28, 2023, revealed that Resident CR1 was discharged home with hospice services on September 15, 2023.
A nurses note dated September 11, 2023, indicated that the resident had fluid filled blisters on both shins approximately the size of a large grape. The entry noted that the physician was aware and new orders were received for furosemide (a diuretic medication) to be given twice daily for three days, an antibiotic cream and dry sterile dressing to be put in place once sites open and begins draining.
Continued review of the resident's clinical record revealed no evidence of any further monitoring/assessment of the fluid filled blisters prior to the resident's discharge on [DATE].
A facility provided Discharge Instructional Packet dated September 15, 2023, indicated that the packet should include a summary of the resident's stay, medication tips and treatments, medication information, incontinence, functional mobility, nutrition, and activities
Review of the resident's Discharge/Transition Plan, which was signed by the resident revealed no summary of the resident's stay, no medication information related to the resident's skin or ordered wound treatments, the nutrition section was incomplete, and the activities section was blank,
At the time of the survey ending September 28, 2023, there was no documented evidence that a discharge summary was provided to the resident or the resident's representative, which included a complete recapitulation of the resident's stay which included wound care provided, the course of illness, corresponding treatment, complete nutrition and activities information, and written discharge instructions related to wound care. The documented discharge summary failed to include an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that the resident transitions safely from the facility to home.
During an interview conducted on September 28, 2023, at approximately 2:00 PM, the nursing home administrator was not able to provide documented evidence that a discharge summary was accurately and fully completed for Resident CR1.
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
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy, and staff interviews it was revealed that the facility failed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy, and staff interviews it was revealed that the facility failed to accurately monitor bowel activity to ensure a physician prescribed bowel protocol was timely implemented as needed for one resident out of 22 sampled residents (Resident 22).
Findings include:
According to the American Academy of Family Physicians {The American Academy of Family Physicians is one of the largest medical organizations in the US founded to promote the science and art of family medicine} the primary goal of constipation management should be symptom improvement, and the secondary goal should be the passage of soft, formed stool without straining at least three times per week).
Review of facility policy entitled Bowel Regimen, last reviewed January 2023 indicated that the purpose of the bowel regimen was to achieve control of bowel evacuation on a regular basis, to avoid constipation, to prevent fecal impaction, and to establish psychological and social well-being. According to the policy, bowel movements are recorded each shift in the point of care system. The 7a-3p supervisor or designee will check the point of care record each morning to determine episodes of diarrhea or constipation and record the names of those residents requiring bowel regimen on the 24-hour report sheet. If no BM for 2 days, administer 4 oz. of prune juice by mouth (dialysis residents only), if no BM for 3 days, on the 4th day during the 7a-3p shift, administer MOM 30 mL by mouth, if no BM for days, on the 5th day during the 3p-11p shift perform abdominal assessment and insert one Dulcolax suppository, if no BM for 5 days, on the 6th day administer a fleets enema on the 11p-7a shift after 5am, and if no bowel movement occurs, registered nurse to perform full bowel assessment, contact MD and obtain further orders.
A review of the clinical record revealed that Resident 22 was admitted to the facility on [DATE], with diagnoses, which included heart disease, Alzheimer's disease, and hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body). Following cerebral infarction affecting left non-dominant side.
A physician ordered bowel protocol for Resident 22 dated September 14, 2023, indicated that staff were to administer Milk of Magnesia (MOM) Suspension 400 mg/5 mL, give 30 cc by mouth every 24 hours as needed for bowel protocol if no BM (bowel movement) on day 4, give MOM with 7 AM to 3 PM morning med pass, and Dulcolax Suppository 10 mg insert one suppository rectally every 8 hours as needed for bowel protocol if no BM on day 5, insert one Dulcolax suppository with 3 PM to 11 PM med pass.
Review of Resident 22's Documentation Survey Report for the month of September 2023 revealed that the resident did not have a bowel movement from September 16, 2023, through September 19, 2023. According to the report, Resident 22 did not have a bowel movement until September 20, 2023, on the 3 PM to 11 PM shift.
Interview with the Director of Nursing on September 28, 2023, at 3:30 PM confirmed that the facility was unable to demonstrate accurate administration of physician ordered bowel regimen during the above time frame without bowel activity.
28 Pa. Code 211.12 (d)(1)(2)(3)(5) Nursing services.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 and staff interviews, it was determined that the facility failed to consistently pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and resident and staff interviews, it was determined that the facility failed to consistently provide services planned to maintain mobility for two of four sampled residents for mobility/range of motion (Resident 7 and 19).
Findings include:
A review of Resident 7's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include intervertebral disc displacement of the lumbar region (degeneration of the disc that separate the bones of the spine, causing pain in the back and legs), and gout (complex form of arthritis).
Resident 7 was discharged from physical therapy on August 15, 2023 with discharge recommendations that Resident 7 was to receive Restorative Nursing Services (RNP) to walk daily, 30-50 feet with a rolling walker, with assist of one person and a wheelchair to follow.
Review of facility document titled Documentation Survey Report v2 dated August 2023, revealed that the daily restorative program for ambulation was not provided 7 days out of the 10 planned daily opportunities, with staff documenting either RR (resident refused) or NA as a response.
Continued review of facility document titled Documentation Survey Report v2 dated September 2023, revealed that the daily restorative program for ambulation was not provided 24 days out of 27 planned daily opportunities, with staff documenting RR or NA as a response.
During an interview with Resident 7 on September 28, 2023, at 10:42 AM the resident expressed concern that she has not ambulated since being discharged from physical therapy in August. Resident 7 stated that she feels as though the numbness in her legs is worsening as a result of not ambulating. The resident also verified that she has not refused participation in her RNP ambulation program and stated that staff do not offer her RNP program.
A review of Resident 19's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses to include Wernicke's encephalopathy (degenerative brain disorder caused by lack of vitamin B1), and abnormalities of gait and mobility.
Resident 19's clinical record revealed that the resident was discharged from physical therapy on February 10, 2023. Discharge recommendations indicated that Resident 19 was to receive Restorative Nursing Services (RNP) for ambulation to walk daily for at least 15 minutes, up to 250 feet with a rolling walker and with stand by assistance.
The resident's Documentation Survey Report v2 dated July 2023, revealed that the daily restorative program for ambulation was not provided 13 days out of 31 planned daily opportunities in the month, with staff documenting RR or NA as a response.
The resident's Documentation Survey Report v2 dated August 2023, revealed that the daily restorative program for ambulation was not provided 11 days out of 31 planned daily opportunities in the month, with staff documenting RR or NA as a response.
The resident's Documentation Survey Report v2 dated September 2023, revealed that the daily restorative program for ambulation was not provided 13 days out of 28 planned daily opportunities, with staff documenting RR or NA as a response.
During an interview with Resident 19 on September 28, 2023, at 1:25 PM the resident confirmed that staff do not provide restorative nursing services daily for ambulation. She stated, they hardly offer to walk me. She also verified that she has never refused an offer to ambulate in the hallway. Resident 19 expressed the desire to walk regularly as she feels she is losing endurance and strength as a result of not walking daily.
Interview with the Nursing Home Administrator on September 28, 2023, at 2:30 PM, confirmed that the facility failed to consistently implement the planned restorative nursing programs for residents to maintain functional abilities and deter declines.
28 Pa. Code: 211.5(f) Medical records
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
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observations, clinical record, and staff interview it was determined that the facility failed to provide care and services designed to prevent potential complications associated with tube fee...
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Based on observations, clinical record, and staff interview it was determined that the facility failed to provide care and services designed to prevent potential complications associated with tube feedings for one resident receiving an enteral feeding out of 21 residents sampled (Resident 17).
Findings include:
A review of the clinical record of Resident 17 revealed admission to the facility on October 13, 2022, with diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) and dysphagia (difficulty swallowing).
Resident 17 required a PEG tube [Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate [for example, because of dysphagia] for enteral feeding [enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements].
A review of physician's orders revealed the following:
On October 13, 2022, the physician ordered flush gastric tube pre and post medication administration with 15 to 30 milliliters water. Staff were to document milliliter totals in POC tasks every shift for patency.
On October 13, 2022, the physician ordered Hydration flushes with 150 ML o water via PEG tube every 4 hours. Document flush amount in POC task every shift.
On October 13, 2022, the physician ordered wash the gastric site with soap and water and apply drain sponge every shift.
On March 29, 2023, the physician ordered Enteral Feeding Glucerna 1.5 via G Tube at a continuous rate of 60 mL for 18 hours. Document total shift intake in POC (point of care) tube feeding task two times a day off at 1100 AM on at 5:00 PM.
Review of Resident 17's plan of care initiated on October 24, 2022, revealed the focus related to the need for tube feeding related to swallowing problems. The care plan failed to identify the type and size of the PEG tube the resident required or how and when to cleanse and provide care to the peg tube site.
A review of the resident's clinical record conducted during the survey ending September 28, 2023, revealed that the amount of pre and post medication flushes, the amount of hydration flushes, and the total intake on the enteral feeding formula was not being documented as per the physician orders.
Observations of the resident's tube feeding and pump on September 28, 2023, at approximately 11:10 AM revealed dried tube feed solution was noted on the pump, stand, pole, and floor.
Interview with the Nursing Home Administrator on September 28, 2023, at approximately 3:45 PM, confirmed that the facility failed to provide care and services designed to prevent potential complications associated with tube feedings and that the facility failed to ensure that tube feeding equipment was maintained in a sanitary manner.
28 Pa. Code 211.12(c)(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
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to provide housekeeping services to mainta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment in resident areas on three of three resident units (First, Second, and Third Floor Nursing Units)
Findings include:
Observations on The First Floor Nursing Unit revealed on September 28, 2023, at 9:50 AM revealed an accummulation of dead insects on the floor at the end of the hall by the heating/cooling unit. The insects included dead stink bugs, dead ants, a dead moth, and dead beetle/roach like bugs.
In resident room [ROOM NUMBER] there was a dead stink bug observed. In the soiled utility room there were multiple dead roach-like bugs along with dead ants.
Observations on The Third Floor Nursing Unit revealed on September 28, 2023, at 10:35 AM revealed dirt and debris on the floor in the hallway.
A used blood glucose strip was observed on the floor in the hallway.
The soiled utility room had a strong foul smell. In the soiled utility room there was a hopper (a flushing rimmed sink used to dispose body fluids) filled with what appeared to be old urine. The urine-like liquid had a film of mold growing on top of it.
At 11:07 AM in resident room [ROOM NUMBER] large pieces of food along with paper debris were observed on the floor was the resident's room.
A dried substance was observed stuck to the floor in resident room [ROOM NUMBER]. Used tissues were observed on the floor. The resident's bedside table was covered with a sticky dried substance.
Interview with the Nursing Home Administrator on September 28, 2023, at approximately 3:45 PM confirmed the facility is to be maintained daily to provide a clean and sanitary environment for the residents.
28 Pa. Code 201.18 (e)(2.1) Management
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
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 necessary to maintain good personal hygiene and grooming of residents' requiring assi...
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Based on clinical record review and staff interview it was determined that the facility failed to provide services necessary to maintain good personal hygiene and grooming of residents' requiring assistance with activities of daily living for two out of five residents reviewed. (Residents 15 and 17).
Findings include:
A review of Resident 15's clinical record revealed admission to the facility on May 3, 2023, with diagnoses which included dementia (persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain). The resident required assistance with activities of daily living, including personal hygiene, showers and bathing.
A review of the resident's clinical record revealed that the resident was to be showered on Monday and Thursdays during the 7 AM to 3 PM shift.
A review of the resident's bathing record for September 2023 revealed that Thursday September 28, 2023, during the 7 AM to 3 PM shift staff provided the resident a bed bath instead of a shower. According to the resident's bathing records, the resident was showered only once during the month of September 2023 as of September 28, 2023.
A review of the resident's current plan of care during the survey on September 28, 2023, revealed that the resident's care plan did not identify or address the required resident's bathing assistance, when the resident was to be showered, or the resident's preferences for bathing.
A review of the clinical record of Resident 17 revealed admission to the facility on October 13, 2022, with diagnoses of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it). The resident required assistance with personal hygiene, bathing and showers.
A review of the resident's clinical record revealed that the resident was to be showered on Mondays and Thursdays on the 3 PM to 11 PM shift.
A review of the resident's bathing record for September 2023, revealed that during the month of September 2023, as of September 28, 2023, the resident had not been showered and received only bed baths.
A review of the resident's current plan of care conducted during the survey on September 28, 2023, revealed that the facility failed to identify or address the resident's need for bathing assistance or when the resident was to be showered. The resident's care plan did not identify the resident's preference to receive bed baths instead of showers.
Interview with the Nursing Home Administrator on September 28, 2023, at approximately 3:45 PM confirmed the facility failed to demonstrate that residents consistently receive service to maintain good personal hygiene and that the facility had developed and implemented planned interventions in accordance with the resident's assessed needs, goals for care, preferences, and address the residents' identified limitations in ability to perform grooming and personal hygiene, to include baths and showers.
28 Pa Code 211.12 (c)(d)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to consistently provide adeq...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to consistently provide adequate supervision and follow physician's orders for measures planned to prevent accidents and promote resident safety three of 21 sampled (Resident 5, 15, and 16)
Findings include:
A review of the clinical record revealed that Resident 5 was admitted to the facility on [DATE], with diagnoses to include a history of falling and orthostatic hypotension (a condition in which your blood pressure suddenly drops when you stand up from a seated or lying position).
A review of a physician's order initially dated September 15, 2023, indicated the resident was to receive 15 minute checks for safety.
A review documentation titled Q 15 Minute Checks revealed that on September 26, 2023, the physician ordered checks were not completed 32 times throughout the day. On September 27, 2023, the physician ordered checks were not completed six times throughout the day.
A review of the clinical record revealed that Resident 15 was admitted to the facility on [DATE], with diagnoses to include lack of coordination and dementia (a condition characterized by progressive or persistent loss of intellectual functioning).
A review of a physician's orders initially dated September 20, 2023, indicated the resident was to receive 15 minute checks for safety.
A review documentation titled Q 15 Minute Checks revealed on September 26, 2023, the physician ordered checks were not completed 32 times throughout the day.
A review of the clinical record revealed that Resident 16 was admitted to the facility on [DATE], with diagnoses to include dementia and abnormal gait and mobility.
A review of a physician's orders initially dated September 6, 2023, indicated the resident was to receive 15 minute checks.
A review documentation titled Q 15 Minute Checks revealed on September 26, 2023, the physician ordered checks were not completed 32 times throughout the day. On September 27, 2023, the physician ordered checks were not completed six times throughout the day.
An interview with the Nursing Home Administrator on September 1, 2022, at approximately 4:00 PM, confirmed the facility failed to provide evidence that the staff had consistently implemented physician ordered safety checks as a planned interventions to provide adequate supervision of these residents.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
Based on a review of clinical records and select facility policy, and staff interview it was determined that the facility failed to ensure that licensed nursing staff possessed the skills and competen...
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Based on a review of clinical records and select facility policy, and staff interview it was determined that the facility failed to ensure that licensed nursing staff possessed the skills and competencies necessary to assure resident safety and administer antibiotics via a PICC line (peripherally inserted central catheter- long thin tube that is inserted through a vein in your arm and passed through to the larger veins near the heart and is used for long-term intravenous antibiotics, nutrition, or medication, and for blood draws) as evidenced by one resident out of 21 residents reviewed (Resident CR1).
Findings Include:
According to the Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understanding and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (1) undertake a specific practice only if the licensed practical nurse has the necessary knowledge, preparation, experience, and competency to properly execute the practice.
Review of the facility Administering Medications by IV Push Policy and Central Venous and Midline Catheter Flushing policy both last reviewed August 2023 indicated that general guidelines include to verify scope of practice and competency requirements with State Nurse Practice Act and RN/LPN scope of practice and functions.
A review of the clinical record of Resident CR1 revealed readmission to the facility on August 9, 2023 with a PICC line and had diagnoses which included diabetes mellitus, left hallux (big toe) amputation, partial first metatarsal ray resection of left foot (procedure used to help salvage the foot and maintain bipedal ambulation), and a right foot ulcer.
A physician order dated August 10, 2023, was noted for Vancomycin HCL (an antibiotic) 750 mg/150 ml once daily intravenously until September 11, 2023, for a diagnosis of osteomyelitis (bone infection).
Review of Resident CR1's August 2023 and September 1 through September 10, 2023 Medication Administration Records revealed that the resident's PICC line care and physician ordered antibiotic was administered by licensed nursing staff, which included licensed practical nurses and registered nurses.
The facility was unable to provided documented evidence that the facility had assured that all employed licensed practical nurses who administered Resident CR1's antibiotic intravenously possessed the appropriate knowledge, preparation, experience, and/or competency to properly care for a resident with a PICC line and administer antibiotics intravenously.
Interview with the administrator and director of nursing (DON) on September 28, 2023, at approximately 2:00 PM indicated that all licensed practical nurses employed at the facility had completed a board-certified class and had the required competency requirements but failed to provide documented evidence at the conclusion of the survey to verify competency as required per facility policy. Interview with the director of nursing and administrator failed to ensure that licensed nursing staff possessed the skills and competencies related to PICC lines and the administration of intravenous antibiotics.
28 Pa. Code 211.12 (c)(d)(1)(3)(5) Nursing Services
28 Pa. Code 211.10(a)(d) Staff development
28 Pa Code 201.19 (3)(7) Personnel policies and procedures
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on review of controlled drug shift count records and select facility policy and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled...
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Based on review of controlled drug shift count records and select facility policy and staff interview, it was determined that the facility failed to implement procedures to promote accurate controlled medication records on two of two medication carts observed.
Finding include:
A review of the current facility provided policy entitled Controlled Substances revealed controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. The oncoming and off going nurse will view the medication together to validate the medication and count is correct.
A review of the facility Narcotic Count Sheet from the first floor medication cart revealed the following:
September 10, 2023, the 3 pm to 11 pm off going nurse failed to sign that the narcotic count to confirm completion of the count;
September 17, 2023, the 3 pm to 11 pm oncoming and the 3 pm to 11 pm off going nurse failed to sign that the narcotic count was completed.
September 20, 2023, the 7 am to 3 pm oncoming and the 7 am to 3 pm off going nurse failed to sign that the narcotic count completed.
September 26, 2023, the 3 pm to 11 pm off going nurse failed to sign that the narcotic count was completed.
A review of the facility Narcotic Count Sheet from the third floor medication cart revealed the following:
September 3, 2023, the 7 am to 3 pm oncoming and the 7 am to 3 pm off going nurse failed to sign that the narcotic count was completed;
September 4, 2023, the 11 pm to 7 am off going nurse failed to sign that the narcotic count was completed;
September 21, 2023, the 7 am to 3 pm oncoming, 7 am to 3 pm off going nurse and the 3 pm to 11 pm oncoming, 3 pm to 11 pm off going nurse failed to sign that the narcotic count was completed;
September 26, 2023, the 3 pm to 11 pm off going nurse and the 11 pm to 7 am oncoming nurse failed to sign that the narcotic count was completed;
September 27, 2023, the 11pm to 7 am off going nurse failed to sign that the narcotic count was accurate and complete;
September 28, 2023, the 7 am to 3 pm oncoming nurse failed to sign that the narcotic count was complete.
Interview with the Director of Nursing on September 28, 2023, at approximately 3:30 PM confirmed the facility failed to demonstrate consistent implementation of facility procedures for promoting accurate controlled drug records.
28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing services.
28 Pa Code 211.9(a)(1)(k)Pharmacy 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
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage of food and supplements to prevent the potential for microbial gro...
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Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage of food and supplements to prevent the potential for microbial growth in food or contamination, which increased the risk for foodborne illness.
Findings include:
An observation on September 28, 2023, at approximately 9:55 AM of the First Floor Nursing Unit dining room revealed a functioning drawer style refrigerator and a drawer style freezer. There was no thermometer in the refrigerator or freezer to monitor for proper temperature.
Upon opening the freezer a large build up of ice that had dislodged fell to the dining room floor. The inside of the freezer was soiled with a dried sticky residue on the bottom shelf.
In the refrigerator in the pantry located next to the dining room, there was an open gallon of milk that was not dated when it was opened, one open gallon of chocolate milk not dated when opened, four containers of ketchup not dated, a jar of homemade canned pickles not labeled with a resident's name or dated, a partially frozen half consumed milkshake type drink not labeled with a name or dated, and a half consumed coffee drink not labeled with a name or dated. In the cabinet there was a used paper towel, used glove and empty food wrapper lying on the shelf. A ring of a dried brown substance was observed on the shelf of the cabinet.
An observation on September 28, 2023, at 10:56 AM of the Third Floor Nursing Unit pantry revealed two open containers of ready care thickened water. The containers were not dated when they were first opened. The manufacturer's instructions indicated that the product maybe kept up to seven days after opening. There was an opened container of vanilla ice cream in the freezer that was not labeled with a resident's name or dated when opened. There was curdled chocolate milk observed lying in the bottom of the sink.
An interview with Nursing Home Administrator on September 28, 2023, at approximately 3:30 PM confirmed the facility failed to maintain acceptable practices for the storage of food and supplements.
28 Pa. Code 211.6 (f) Dietary services.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observation and staff interviews, it was determined that the facility failed to consistently provide a fully functioning call system to provide direct communication from the resident to the c...
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Based on observation and staff interviews, it was determined that the facility failed to consistently provide a fully functioning call system to provide direct communication from the resident to the caregivers for 4 of 21 residents sampled (15, 18, 25 and 26)
Findings included:
Observations on the third floor nursing unit on September 28, 2023, at approximately 2:00 PM revealed Resident 15's call bell was unplugged from the wall. The call bell was observed lying on the floor under the resident's bed.
Observation revealed that Resident 18's call bell was unplugged from the wall. The call bell was not accessible to the resident and was found lying under the resident's bed.
Resident 25's call bell was unplugged from the wall. The call bell was found under a chair in the room and not accessible to the resident.
Resident 26's call bell was unplugged from the wall. The call bell could not be located in the resident's room. The call belly system was not functional for this resident's use.
Interview with the nursing home administrator (NHA) on September 28, 2023, at approximately 4:00 PM confirmed that the facility failed to have a fully functioning call bell system for resident use.
28 Pa Code 205.67(j)(k) Electric requirements for existing construction.
Aug 2023
18 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument Manual, a review of clinical records and staff interviews, it was determin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument Manual, a review of clinical records and staff interviews, it was determined that the facility failed to complete a Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) comprehensive admission assessment within the required time frame for one of 27 residents sampled (Resident 41)
Findings include:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS) dated [DATE], requires that Comprehensive admission Assessment completion date (Item Z0500B) must be competed no longer than the resident's admission date + 13 calendar days.
A clinical records review revealed that Resident 41 was admitted to the facility on [DATE].
A review of Resident 41's MDS Comprehensive admission assessment dated [DATE] revealed that the assessment was completed 16 days following the resident's admission (2 days overdue).
An interview with the Director of Nursing on August 18, 2023, at approximately 10:15 a.m., confirmed that the MDS Comprehensive admission Assessment for Resident 41 was not completed within the required time frame.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument Manual, a review of clinical records and staff interviews, it was determin...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument Manual, a review of clinical records and staff interviews, it was determined that the facility failed to transmit Minimum Data Set (MDS, a federally mandated standardized assessment conducted at specific intervals to plan resident care) assessments to the required electronic system, the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System, within the required time frame for one of four closed records reviewed (Resident 74).
Findings included:
The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the Minimum Data Set (MDS) dated [DATE], requires that Discharge Assessment-Return Not Anticipated (Non-Comprehensive) be completed no longer than the resident's discharge date + 14 calendar days.
A clinical record review revealed that Resident 74 left the facility and was admitted to the community hospital on May 17, 2023. The resident did not return to the facility. A clinical record review revealed that a MDS Discharge Assessment-return not anticipated was not completed as of August 17, 2023 (78 days overdue).
An interview with the Director of Nursing on August 18, 2023, at approximately 10:15 a.m. confirmed that the MDS Discharge Assessment-return not anticipated assessment, for Resident 74 was not submitted within the required time frame.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and the Resident Assessment Instrument and staff interviews, it was determined the facility failed to ensure the Minimum Data Set Assessments (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one resident out of 27 sampled (Resident 9).
Findings include:
A review of Resident 9's clinical record revealed the resident was admitted to the facility on [DATE].
A review of Resident 9's quarterly MDS assessment dated [DATE], indicated in Section K0300 Weight Loss that the resident had a loss of 5% or more in the last month or loss of 10% or more in 6 months. The resident was not on a physician prescribed weight loss regimen.
A Nutrition note in the resident's clinical record dated June 5, 2023 at 1:09 p.m. indicated that the resident's weight loss is significant, planned, and desirable per the resident, making the quarterly MDS assessment dated [DATE] inaccurate.
Interview with the Director of Nursing on August 17, 2023 at 2:10 p.m. she confirmed the resident was on a planned weight loss program making the quarterly MDS assessment dated [DATE] inaccurate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records, and staff and resident interviews, it was determined that the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records, and staff and resident interviews, it was determined that the facility failed to develop and implement an individualized comprehensive care plan to meet the daily care needs of one out of the 27 residents sampled (Resident 3).
Findings included:
Clinical record review revealed that Resident 3 was admitted to the facility on [DATE], with a diagnosis of metabolic encephalopathy (a syndrome of temporary or permanent disturbance of brain functions) and 10F left nephrostomy tube (a opening between the kidney and the skin. A nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects; urine drains through the tube into a bag outside your body. The bag has a tap so you can empty it) in place.
A review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated May 10, 2023, indicated the resident was cognitively intact with a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 10 (a score of 8 to 12 indicated that the resident is moderately cognitively impaired).
Resident 3's care plan noted that the resident was at risk for infection with a nephrostomy tube, dated April 19, 2023, with planned interventions to educate resident on infection control practices and techniques to prevent infection, encouraging fluids, evaluating for diarrhea, nausea, vomiting, lung sounds, skin appearance surrounding the nephrostomy tube, sputum characteristics, temperature, flu, and pneumococcal vaccine status, monitoring for increased cough and signs of infection, reviewing lab results, meal intake, and staff following standard precautions, including proper handwashing techniques to minimize microorganism transmission.
However, the resident's care plan failed to identify the the techniques and frequency for the staff and/or resident to care for the resident's nephrostomy tube, including the daily care, inspection, draining and flushing and other precautions necessary to prevent complications and infection.
A clinical record review revealed that Resident 3 was hospitalized on [DATE], with a urinary tract infection (bacterial infection of the bladder and associated structures) and sepsis (impaired whole-body immune response to an infection).
While hospitalized , the resident had physician orders to (1) empty the left nephrostomy each shift and document the amount every shift for the nephrostomy tube; (2) assure the nephrostomy tube is intact, patent, and monitored for symptoms of infection or blockage every shift, and (3) change the nephrostomy dressing 4 times a day and as needed, which were discontinued on June 15, 2023, when the resident was re-admitted to the facility
At the time of the survey ending August 18, 2023, the were no current physician orders for nephrostomy care to Resident 3.
An observation of resident room [ROOM NUMBER] on August 15, 2023, at 12:40 p.m. revealed a urine collection graduate filled with a dark yellow urine-like liquid on top of Resident 3's heating and cooling unit. During an interview, at that time, Resident 3 stated that nursing staff left the urine there for the resident to empty after assisting with the resident's care.
During an interview at 1:00 p.m., Employee 3, a nurse aide, stated that some residents are independent and able to carry out care tasks. Employee 3 stated that the urine should not be left sitting there (referring to Resident 3's heating and cooling unit). Employee 3 was unable to state if Resident 3's care plan was for the resident to independently empty the nephrostomy bag.
During an interview on August 17, 2023, at 1:30 p.m., the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed the resident's care plan failed to reflect the resident's nephrostomy care needs.
28 Pa. Code 211.12(c)(d)(1)(5) Nursing Services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident and staff interviews and a review of clinical records and staff interviews, it was determined that the facil...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a resident and staff interviews and a review of clinical records and staff interviews, it was determined that the facility failed to develop and implement an individualized discharge plan for one of the 27 residents reviewed (Resident 87) to reflect the resident's discharge goals.
Findings included:
Clinical record review revealed that Resident 87 was admitted to the facility on [DATE], with diagnoses that included peripheral vascular disease and had a right leg above the knee amputation.
A review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated May 10, 2023, indicated the resident was cognitively intact with a BIMS (brief interview mental screener that aids in detecting cognitive impairment) score of 15 (a score of 13 to 15 indicated that the resident was cognitively intact).
During an interview on August 15, 2023, at 1:35 p.m., Resident 87 stated, I have made it very clear that I want to go home. During the interview, the resident stated that the plan was to have a leg prosthetic adjusted, participate in a rehabilitation program, and then return to the community. The resident also stated that living at home may not be a possibility, because of a recent separation and divorce.
A clinical record review revealed a physician progress note dated July 19, 2023, at 10:53 a.m., indicating that Resident 87 is highly motivated, has a goal of returning home independently, and before that, can hopefully transfer to an assisted living facility. The note also indicated that the resident wants to resume activities such as self-care, cooking, chores, laundry, and personal hygiene.
A review of social service notes, conducted during the survey ending August 18, 2023, revealed no documentation of discharge planning since February 14, 2023.
A review of the resident's care plan initially dated April 27, 2022, and as of the survey ending on August 18, 2023, revealed no documented evidence that an individualized discharge plan was developed and revised as needed to reflect the resident's desire for discharge.
During an interview on August 17, 2023, at 1:45 p.m., the Nursing Home Administrator and Director of Nursing confirmed that there was no documented evidence of a current individualized discharge plan identifying the resident's current preferences for discharge and measures needed to meet the resident's desired discharge goal.
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 review of clinical records and resident and staff interview it was determined the facility failed to consistently provi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and resident and staff interview it was determined the facility failed to consistently provide person-centered care for a resident requiring hemodialysis (medical procedure to remove fluid and waste products from the blood and to correct electrolyte imbalances; accomplished using a machine and a dialyzer) by failing to assure the resident was was transported to dialysis with the necessary equipment to assure the resident's dialysis treatment was provided as scheduled for one of two residents sampled. (Residents 23).
Findings include:
A review of the clinical record revealed that Resident 23 was admitted to the facility on [DATE], with a diagnosis of end stage renal disease and was receiving hemodialysis.
Interview with the resident on August 16, 2023 at 10:15 a.m. revealed that the resident stated that the dialysis center sent her back to the facility this morning without providing her treatment because the facility did not send her (lift) sling needed to transfer her (via the mechanical lift), with the resident to the scheduled dialysis appointment. Resident 23 stated that normally the nurse aides put the sling under her in the wheelchair before she leaves the facility. She also stated that the nurse aides on the night shift that day were agency nurse aides and did not send the sling with her to dialysis and due to the lack of the sling for transfers, she was sent back to the facility without receiving dialysis.
Interview with Employee 4 (Nurse Aide) on August 16, 2023, at 11 AM revealed that Resident 23 required the use of a hoyer lift for transfers and needs a sling for transfers. She also stated that when Resident 23 leaves the facility for dialysis the sling should be sent to dialysis so they can transfer the resident from the wheelchair she takes to the dialysis chair.
The resident was sent back to the facility with receiving scheduled dialysis treatment on August 16, 2023, and had to be rescheduled for dialysis the next day, August 17, 2023, because the dialysis center was unable to transfer the resident from her wheelchair to the Dialysis chair with the lift the sling.
Interview with the Director of Nursing on August 16, 2023 at 11:30 a.m. confirmed that Resident 23 was sent back to the facility and did not receive her scheduled dialysis treatment on August 16, 2023, because the facility nursing staff failed to send the lift sling with the resident in to transfer the resident from the wheelchair to the dialysis chair that morning.
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 F0740
(Tag F0740)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interviews, it was determined that the facility failed to ensure each resident received the necessary behavioral health care in a timely manner to attain or maintain the highest practicable mental and psychosocial well-being for one of 25 residents sampled (Resident 1).
Findings include:
Review of clinical record of Resident 1 revealed that the resident was admitted to the facility on [DATE], with diagnoses including autism.
Further review of Resident 1's clinical record revealed that the resident exhibited multiple behaviors, including stealing other residents' food and clothing, rummaging through linen carts, pacing, attempting to hit staff, and removing his urinary foley bag. Resident 1 was noted to have an increase in these behaviors beginning July 2023, according to a review of progress notes, culminating in an incident on August 14, 2023 during which Resident 1 scratched the nurse aide who was providing morning care arms hard enough to draw blood and continued to attempt to assault staff.
Review of Resident 52's care plan, initiated by the facility on May 11, 2011, indicated that the resident has a behavioral problem. However, the resident's care plan did not address the resident's specific behavioral problems or symptoms noted in the nursing documentation. Interventions planned were to intervene if resident was putting others at risk, and medications per physician orders.
Review of Resident 1 nursing progress notes in the resident's clinical record between July 8, 2023, and August 14 2023, revealed that the resident also continued to consistently exhibit behaviors of attempting to eat other residents' food and attempting to strike staff.
There were no new or revised behavioral interventions for staff to employ added to the resident's care plan following the increase in behaviors beginning July, 2023, to manage or modify the resident's behaviors of trying to eat other's food, yelling at staff and attempting to strike out at staff, which were continuing through end of survey August 18, 2023.
According to Resident 1's clinical record, staff were to track the resident's behaviors on the resident's Medication Administration Record (MAR). A review of the resident's MARs, which staff completed for Resident 1 from July 2023, through end of survey August 18, 2023, revealed that staff were not consistently tracking the resident's specific behaviors targeted for monitoring. There were no interventions identified for staff to use when the resident displayed the specific targeted behaviors that were to be monitored and tracked.
There was no documented evidence of the use of interventions or tracking of resident behaviors to identify any patterns (such as time of day, environmental stimuli, etc.), trends (frequency of similar behaviors) or other potential triggers to develop and implement behavior management or modification plans for the resident.
There was no evidence that the facility had developed and implemented plans to provide meaningful activities, which promote resident engagement based on the resident's customary routines, interests, preferences, to enhance the resident's mental health and well-being.
Interview with the Director of Nursing and Nursing Home Administrator on August 17, 2023, at approximately 1:30 PM verified that the facility was unable to provide evidence that the facility tracks resident behaviors and/or interventions used in response, as part of behavior management or modification plans. There is no mechanism in place to assess the effectiveness of any behavioral management approaches, diversional activities, or behavioral modification interventions noted on the resident's care plan.
28 Pa. Code 211.12 (d)(3)(5) Nursing services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records and select facility incident reports, and staff interview, it was determined ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, a review of clinical records and select facility incident reports, and staff interview, it was determined that the facility failed to fully develop and implement an individualized person-centered plan to address a resident's dementia-related behavioral symptoms for one out of the 27 residents sampled (Residents 111).
Findings included:
A review of the clinical record revealed that Resident 111 was admitted to the facility on [DATE], and had diagnoses that included unspecified cerebrovascular disease (a group of conditions that affect blood flow and the blood vessels in the brain).
A quarterly Minimum Data Set assessment (a federally mandated standardized assessment completed periodically to plan resident care) dated August 2, 2023, indicated that Resident 111 is severely cognitively impaired and exhibits inattention, disorganized thought, threatening, screaming, or yelling at others.
A psychiatric evaluation and history dated June 1, 2023, indicated that Resident 111 during a psychiatric consult on April 25, 2023, the resident was diagnosed with vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). The psychiatric provider notes dated June 11, June 17, July 28, July 30, August 4, August 6, and August 11, indicated that Resident 111 had vascular dementia and dementia with other behavioral disturbances of impulsivity, delusional thinking, anxiety, visual hallucinations, and paranoia.
Resident 111's care plan, initially dated May 6, 2023, failed to address the resident's dementia behaviors associated with the resident's dementia diagnosis and corresponding individualized person-centered interventions to target those behaviors.
Resident 111's care plan did note a behavior problem of accusatory statements towards staff and others, yelling at roommates, playing with feces, throwing food, shouting at staff and others, throwing personal items at staff, stating she was bit by an alligator, wandering, and being unable to redirect with planned interventions dated June 16, 2023, for administering medications as ordered, anticipating and meeting the resident's needs, assisting the resident to develop more appropriate methods of coping and interacting, explaining procedures to the resident before starting and allowing the resident time to adjust if reasonable, discussing the resident's behavior, explaining or reinforcing why behavior is inappropriate and/or unacceptable, intervening as necessary to protect the rights and safety of others, approaching or speaking in a calm manner, diverting attention, removing from the situation, and taking to an alternate location as needed.
Planned interventions added on June 30, 2023, included updating MD on labs and diagnostic testing as ordered and utilizing two staff for care.
The resident's care plan related to behaviors was not updated or revised since June 30, 2023, until following the surveyor inquiry during the survey of August 18, 2023.
A nursing progress note dated July 25, 2023, at 10:32, indicated that the resident was yelling about the devil and refusing to take ordered medications.
A nursing progress note dated August 4, 2023, at 4:51 a.m., indicated that Resident 111 was uncontrollable throughout the night, screaming at the top of lungs, cursing profanities at other residents and staff, throwing objects, and grabbing and scratching staff. The entry indicated that the resident goes in and out of other residents' rooms.
A CRNP (Certified Registered Nurse Practitioner) note dated August 4, 2023, at 4:01 PM indicated that Resident 111 has been intermittently having behaviors and psychosis, very aggressively yelling at staff, and trying to be abusive towards others. The note also indicated that the resident was very hard to redirect.
During an observation on August 15, 2023, at 11:55 a.m., Resident 111 was observed throwing a water bottle, yelling at staff, and telling this surveyor to mind your own business, when greeted with hello. At the time of the observation the resident was not provided with any individualized activities or engagement. The resident was under a 1:1 (one staff member to one resident) level of supervision.
At the time of the survey ending on August 18, 2023, there was no documented evidence that the facility had developed and implemented a person-centered plan to manage the resident's dementia-related symptoms, including providing the resident with individualized activities and engagement to deter the resident's physical and verbal aggression. The facility was unable to provide evidence that it attempted to provide meaningful activities that addressed Resident 111's past customary routines, interests, preferences, and choices to enhance the resident's well-being.
An interview with the Nursing Home Administrator and Director of Nursing on August 16, 2023, at 1:15 p.m. confirmed there was no documented evidence that the facility identified dementia-related behaviors and implemented individualized interventions to effectively address and monitor Resident 111's dementia-related behavioral symptoms.
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 F0849
(Tag F0849)
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 staff interview, it was determined that the facility failed to ensure coordina...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interview, it was determined that the facility failed to ensure coordination of Hospice services with facility services to meet the resident's needs on a daily basis for two out of two resident reviewed receiving hospice services (Residents 51 and 22).
Findings include:
A review of the clinical record revealed that Resident 51 was admitted to the facility on [DATE], with diagnoses of alzheimer's disease.
The resident was admitted to hospice services on July 23, 2023 for end stage Alzheimer's disease.
Review of Resident 51's plan of care, conducted during the survey ending August 18, 2023, revealed the plan of care was not integrated with hospice services and measures planned to assure that nursing home staff coordinate and monitor the delivery of resident care in conjunction with the hospice provider services to meet the resident's needs.
A review of the clinical record revealed that Resident 22 was admitted to the facility on [DATE] with diagnoses of COPD (chronic obstructive pulmonary disease-group of lung diseases that block airflow and make it difficult to breathe).
The resident was admitted to hospice services on April 18, 2023 for end stage COPD.
Review of Resident 22's plan of care conducted during the survey ending August 18, 2023, revealed the plan of care was not integrated with hospice services and measures planned to assure that nursing home staff monitor the delivery of care in order to assure that the hospice provides services to the resident meets the resident's needs.
There was no evidence that the hospice and the nursing home collaborated in the development of a coordinated plan of care for each resident receiving hospice services to identify the provider responsible for performing each or any specific services/functions that have been agreed upon and the location of the necessary plans.
Observation while on the third-floor nursing unit where Resident 22 resides on August 17, 2023 at 1:10 PM revealed no evidence of a weekly schedule available for facility staff to be aware when and where hospice would be at the facility to care for Resident 22.
Interview with employee 1 (registered nurse supervisor) at this time confirmed the schedule was not available.
During interview with the Director of Nursing (DON) on August 17, 2023, at 2:00PM she confirmed that hospice care plans were not integrated with the facility plans of care. The DON confirmed that a schedule was to be provided by hospice to coordinate resident care.
28 Pa. Code 211.12 (d)(3)(5) 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 a review of clinical records, select facility policy, current CDC (Centers for Disease Control and Prevention) and PAHAN (Pennsylvania Health Alert Network) infection control guidance, observ...
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Based on a review of clinical records, select facility policy, current CDC (Centers for Disease Control and Prevention) and PAHAN (Pennsylvania Health Alert Network) infection control guidance, observations and staff interview, it was determined the facility failed to consistently implement infection control precautions necessary to deter the spread of the COVID-19 virus in the facility as evidenced by one resident testing positive for Covid-19 (Resident 28).
Findings include:
A review of the Pennsylvania Department of Health 2023 - PAHAN - 694 - 5-11-UPD dated May 11, 2023, subject: UPDATE: Interim Infection Prevention and Control Recommendations for COVID-19 in Healthcare Setting. This HAN update provides comprehensive information regarding infection prevention and control for COVID-19 in healthcare settings based on changes made by the Centers for Disease Control and Prevention (CDC) on May 08, 2023
Isolation for residents: The term isolations refer to the implementation of measures for a resident with COVID-19 infection during their infectious period, to prevent transmission to other residents, health care professionals, or visitors.
Isolation in long term care facility residents includes the use of standard and transmission- based precautions for COVID-19 and a private room with a private bathroom or another resident with laboratory confirmed COVID-19, preferably in a COVID Care Unit and restrict the resident to their room with the door closed. (In some circumstances keeping the door closed may pose resident safety risks and the door might need to remain open. If the door remains open, work with facility engineers to implement strategies to minimize airflow into the hallway).
An outbreak is considered one or more COVID-19 cases in a facility.
If residents develop signs and symptoms of COVID-19 perform viral testing, implement isolation while tests are pending and place unvaccinated roommate(s) under quarantine immediately. Do not place a person with suspected COVID-19 into a COVID care unit prior to confirmation of infection by positive test result.
Patient placement: Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). The patient should have a dedicated bathroom. If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Multidrug-resistant organism (MDRO) colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process. Limit transport and movement of the patient outside of the room to medically essential purposes.
Quarantine for residents should extend 10 days from the date of the last exposure, regardless of the results of testing, unless the resident should become symptomatic or positive for SARS-CoV-2 during that period.
A review of the facility policy entitled Coronavirus Disease (Covid-19) - Infection Prevention and Control Measures last revised May 2023, revealed that effective cohorting of residents as indicated.
Review of the facility's COVID-19 tracking revealed that Resident 28 tested positive on August 7, 2023.
A tour of the facility on August 16, 2023, revealed that the facility has a licensed/certified bed capacity of 180 beds. The census on August 26, 2023, was 132, with 48 remaining available beds. During the tour it was observed that Resident 28 had a roommate. The roommate (Resident 29) was not in the room at the time of the observation, but nursing staff stated that he was outside visiting with family. Resident 29 continued to reside in the same room with COVID positive Resident 28 since August 7, 2023. Resident 29 was tested for Covid-19 on August 7, 2023, and tested negative at that time.
Following surveyor inquiry on August 16, 2023, the facility asked Resident 29 if he wanted to move his room, but by that time Resident 28 only had 1 more day of isolation remaining and Resident 29 declined the move.
The facility was unable to provide evidence that the facility had explained the risk for infection to Resident 29 and his nephew, who was visiting with the resident on August 16, 2023, of Resident 29 staying in the room with Resident 28, when Resident 28 tested positive on August 7, 2023, for Covid-19.
Interview with the Administrator on August 16, 2023 at 11:30 a.m. the NHA was unable to state why the facility failed to isolate Resident 28 in a private room or cohort the resident with another COVID positive resident.
28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services
28 Pa. Code 201.18 (e)(1) Management
28 Pa. Code 211.10(a)(c)(d) Resident care policies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to demonstrate that the resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview, it was determined that the facility failed to demonstrate that the resident or the resident's representative was provided education regarding the benefits and potential side effects of the influenza and pneumococcal immunizations, and that the resident either received the immunizations or did not receive the immunizations due to medical contraindication or refusal for three residents out of eight residents reviewed (Residents 4, 98, and 106).
Findings include:
Review of Resident 4's clinical record revealed admission to the facility on July 27, 2015. The resident was offered the influenza immunization on October 31, 2022, and refused the immunization. However, there was no documentation in the resident's clinical record that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza immunization, and that the resident either received the immunizations or did not receive the immunization due to medical contraindication or refusal.
Review of the clinical record for Resident 98 indicated that he was admitted to the facility on [DATE]. The resident was offered the pneumococcal immunization on June 24, 2022 and refused the immunization. There was no documentation in the resident's clinical record that the resident or resident's representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization, and that the resident either received the immunizations or did not receive the immunization due to medical contraindication or refusal.
Review of the clinical record for Resident 106 indicated that she was admitted to the facility on [DATE]. The resident was offered the influenza and pneumococcal immunization on December 6, 2022, and the resident refused the pneumococcal immunization but accepted the influenza immunization. There was no documentation in the resident's clinical record that the resident or resident's representative was provided education regarding the benefits and potential side effects of the influenza, pneumococcal and that the resident either received the immunizations or did not receive the immunizations due to medical contraindication or refusal. Also there was no documentation that the resident received the influenza immunization after the acceptance on December 6, 2022.
Interview with the Administrator on August 17, 2023 at 10:30 a.m. confirmed the above findings.
28 Pa Code 211.12 (c)(d)(1)(5) Nursing services
28 Pa Code 201.29 (a) Resident rights
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0943
(Tag F0943)
Could have caused harm · This affected 1 resident
Based on staff interviews and a review of facility training and orientation records the facility failed to provide training to their staff on activities that constitute abuse, neglect, exploitation, o...
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Based on staff interviews and a review of facility training and orientation records the facility failed to provide training to their staff on activities that constitute abuse, neglect, exploitation, or the misappropriation of resident property and resident abuse prevention for one of 9 employees interviewed (Employee 1)
Findings included:
During an observation conducted on the second floor on August 16, 2023, at 9:45 a.m., Employee 1 was observed working in the nursing station. An interview at this time revealed that Employee 1 was an outside agency registered nurse supervisor working at the facility for the first time on the day of this interview. Employee 1 stated that the facility did not provide training on abuse, neglect, exploitation, or misappropriation of resident property and resident abuse prevention.
During an interview on August 16, 2023, at approximately 1:15 p.m., the Nursing Home Administrator confirmed that the facility did not provide training Employee 1 training on abuse, neglect, exploitation, or misappropriations of resident property and resident abuse prevention to employee 1 prior to working as a registered nurse supervisor at the facility.
28 Pa. Code 201.20(b) Staff development
28 Pa. Code 201.29(a)(c) Resident rights
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and a staff interview, it was determined that the facility failed to provide housekeeping and maintenance ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and a staff interview, it was determined that the facility failed to provide housekeeping and maintenance services to maintain a clean, orderly, and homelike environment in resident areas on two of three resident units (Units 2 and 3).
Findings included:
An observation on August 15, 2023, at 10:30 a.m. of resident room [ROOM NUMBER] revealed a build-up of a white powdery substance covering the red electrical outlet, black electrical cord, and chair legs adjacent to the door-side bed.
An observation on August 15, 2023, at 10:40 a.m., of resident room [ROOM NUMBER] revealed a tan floor mat, to left of the bed located by the door, that had black scuff marks, brown stains, and areas of build-up of black substance Observation of the residents' bathroom revealed a toilet cleaning brush hanging on the assist bar behind the toilet.
An observation on August 15, 2023, at 10:45 a.m., of resident room [ROOM NUMBER] revealed brown and tans stains on the top and front cover of the heating and cooling unit and debris and dirt were observed in the unit's vents.
An observation on August 15, 2023, at 11:08 a.m., of resident room [ROOM NUMBER] revealed white marks on the plaster measuring 3 inches x 7 inches, black scuff marks on the molding strip and scratches on the wall to the left of the sink in the resident's bathroom.
An observation on August 15, 2023, at 11:13 a.m., of the bathroom in resident room [ROOM NUMBER] horizontal scratches running along the bottom of the door. Black scuff marks, areas of chipped paint, and dents were observed the bathroom door frame. Also, peeling paint was visible to the left and right of the restroom door, leaving white drywall exposed. Smears of a light green substance and chips in the wall, revealing white drywall below the window.
An observation on August 15, 2023, at 11:23 a.m., of resident room [ROOM NUMBER] revealed horizontal scratches running along the bottom of the bathroom door. Exposed white drywall and peeled paint were observed to the right of the bathroom door. A 4-foot horizontal cut with frayed paint and exposed drywall of the bathroom wall. The interior restroom door frame was observed with black scuff marks, dents, and areas of chipped paint. Breaks in the plaster on wall behind the bed by the door, measuring 12 inches x 5 inches and several areas of smaller breaks in the plaster were observed.
An observation on August 15, 2023, at 11:25 a.m. of resident room [ROOM NUMBER] revealed large red and brown colored stains on the privacy curtains. An unlabeled bedpan was observed on the assist bar to the left of the toilet in the resident bathroom. Two ceiling blocks in the residents' bathroom were stained, with round tan stains measuring approximately 5 inches in diameter. Black and gray stains were observed on the wall and floor molding in the resident bathroom. A build-up of dirt and a black substance and were observed behind the toilet. [NAME] stains were observed at the base of the toilet.
An observation on August 15, 2023, at 11:37 a.m. revealed a 3-foot scratch mark and gray scuffs on the wall above the wooden handrail in the hallway between resident rooms #235 and #237.
An observation on August 15, 2023, at 11:50 a.m. in resident room [ROOM NUMBER] revealed that the light above the sink in the residents' bathroom was not functioning.
An observation on August 15, 2023, at 12:06 p.m., of resident room [ROOM NUMBER] revealed a smear of dark green substance, measuring 2 feet x 2 feet on the wall and the floor molding to the right of the window.
An observation on August 15, 2023, at 12:37 p.m., of resident room [ROOM NUMBER] revealed a urine collection graduate placed on the heating and cooling unit containing a dark yellow urine-like liquid substance inside.
An observation on August 16, 2023, at 10:30 a.m. revealed the privacy curtains in resident room [ROOM NUMBER] were stained with dried red stains. Observation of the toilet in the resident bathroom revealed what appeared to be a dried feces on and around the toilet. An observation of resident room [ROOM NUMBER] revealed large stains and discolorations on the privacy curtains.
An observation on August 18, 2023, at 8:21 a.m. in the dining room of the locked unit 2, revealed a small couch with two seat cushions that did not match. The fabric on the chairs in the dining room was discolored. [NAME] and gray stains were observed on the heating and cooling unit. A hardened pink liquid spill was observed a brown wooden cabinet and on the floor, and on the wall near the cabinet.
An observation on August 18, 2023, at 8:23 a.m. revealed a tan garbage can with brown, black, and grey stains covering the lid in the open dining/day room on Unit 2.
An observation on August 18, 2023, at 8:25 a.m. revealed a 2-inch tear in the fabric of a green couch on the right side and black stains on the top of the left side arm rest in the Unit 3 dining/day room. The fabric was faded and discolored on the red and tan checkered couch. A red stain and gray marks were observed on the heating and cooling unit. Stains were observed on the front seat section of a green and red chair.
During an interview on August 18, 2023, at approximately 11:00 a.m., the Director of Nursing (DON) confirmed that the residents' environment should maintained in a clean, orderly and homelike manner.
28 Pa Code 201.18(e)(2.1) Management
28 Pa Code 201.29(a) Resident Rights
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of grievances filed with the facility and the minutes from resident group meetings and staff interviews it was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of grievances filed with the facility and the minutes from resident group meetings and staff interviews it was determined that the facility failed to put forth sufficient efforts to promptly resolve continued resident complaints and grievances expressed during Resident Council meetings, including those voiced by six (6) of the seven (6) residents (Residents 16, 20, 25, 52, 65, and 101).
Findings included:
A review of the minutes from the May 2023 through July 2023 Resident Council and Town Hall meetings revealed that residents in attendance at these meetings voiced their concerns regarding the facility's laundry services and long waits for staff to respond to their call bells. The minutes from several Resident Council meetings indicated that concerns with facility laundry services were referred to a laundry/housekeeping meeting (Town Hall).
During the May 1, 2023, Resident Council Meeting, the residents voiced several concerns related to missing clothing articles. Individual grievances were filed for each resident.
A review of grievances revealed a grievance filed on May 1, 2023, by Residents 67 and 101 at a Resident Council Meeting on May 1, 2023, reporting that 2nd shift staff wear ear buds and talk on their phones while providing resident care. There was no documented evidence that the facility communicated a response to the residents' regarding this grievance.
During the June 2023 town hall meeting, the residents expressed concerns over not having second shift laundry services. There was no evidence that a grievance was filed on behalf of the residents at or following this meeting or evidence of facility follow up efforts communicated to the residents.
During the July 6, 2023, Resident Council Meeting, the residents voiced complaints about having difficulty reaching into the washing machine because it is a top loader. There was no evidence that a grievance was filed regarding laundry services or equipment at or following the meeting or evidence of the facility's efforts to address the residents' concerns.
A review of grievances revealed a grievance filed by Residents 67 and 101 on July 6, 2023 following a Resident Council Meeting, indicating that the residents were waiting for a meeting with housekeeping. The residents were informed that housekeeping all went home for the day. There was no documented evidence that the facility communicated a response to the residents' grievance regarding the residents meeting with housekeeping staff to resolve their complaints.
During the July 2023 town hall meeting, the residents expressed concerns over clothing not coming back from laundry services in 24 hours. Residents in room [ROOM NUMBER] relayed that their clothes were not returned in five days after being sent to the laundry. There was no evidence that a grievance was filed on behalf of residents expressed concerns at or following the meeting or that the facility had adequately addressed the residents' concerns.
During the August 2023 town hall meeting, the residents reported that their personal clothing was not being returned 48 hours after sending articles to laundry.
During a group meeting held on August 16, 2023, at 10:00 a.m. with seven (6) alert and oriented residents, six (6) residents (Residents 16, 20, 25, 52, 65, and 101) the residents all stated that laundry services remains a problem. The residents stated that clean linens are often not available in the morning, and personal articles of clothing often go missing. The residents also reported that the staff response to their call-bells is slow. Residents 101 and 65 stated that after they file a grievance or make a complaint, the facility fails to follow up with them. The residents reported that these issues have continued without resolution to date.
The facility was unable to provide documented evidence that it had determined if the residents' felt that their complaints or grievances had been resolved through any efforts taken by the facility in response to the residents' expressed concerns regarding laundry services and call bell response times that were brought up at Resident Council Meetings and Town Hall Meetings.
During an interview on August 17, 2023, at approximately 1:00 p.m., the Nursing Home Administrator and Director of Nursing were unable to provide documented evidence that the facility had followed up with the residents to ascertain the effectiveness of the facility's efforts in resolving their complaints regarding laundry services and the facility's issues concerning call bell response.
28 Pa. Code 201.18(e)(1)(4) Management
28 Pa. Code 201.29 (a) Resident Rights
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 clinical records and staff interview it was determined that the facility failed to ensure that a resident d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview it was determined that the facility failed to ensure that a resident dependent on staff for assistance with activities of daily living consistently received showers as planned to maintain good personal hygiene for one of four residents sampled (Resident 126).
Findings include:
A review of Resident 126's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia (chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning).
An admission Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) of Resident 126 dated July 12, 2023, indicated that the resident was totally dependent on staff for bathing/showers. The resident was moderately cognitively impaired with a BIMS score of 8 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 8 indicates the resident is moderately cognitively impaired.
A review of the July 2023 Task Documentation Report (care tasks completed for the resident) revealed that the resident was to be showered on Mondays and Thursdays, and as needed, on the 7:00 AM to 3:00 PM shift.
Further review of the Task Documentation report from July 6, 2023, through July 27, 2023, revealed that Resident 126 received a bed bath on July 7, July 8, July 10, July 20, and July 27, 2023. The resident received a shower on Thursday July 13, 2023, seven days after admission to the facility, and again on Monday July 17, 2023. On Monday July 24, 2023 the resident was noted to have refused a shower (no reason for the refusal was noted).
There was documented evidence that the facility showered the resident twice each week as planned. There was no documented evidence that the resident preferred a bed bath instead of a shower.
During interview with the director of nursing (DON) on August 18, 2023 at approximately 11:00 AM the DON confirmed that Resident 126 should have been showered as scheduled.
28 Pa. Code 211.12 (c)(d)(5) Nursing services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview it was determined that the facility failed to consistently monitor resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and staff interview it was determined that the facility failed to consistently monitor resident weights as planned for three residents (Residents 105, 9 and 106) and implement measures to maintain or improve declining nutritional parameters for one resident of five sampled (Resident 55).
Findings include:
Review of the facility policy Weight Assessment and Intervention last reviewed August 7, 2023, indicated that any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation.
Clinical record review revealed that Resident 105 had diagnoses which included quadriplegia (paralysis of all four limbs and the torso).
Review of Resident 105's resident's weight record revealed that on December 3, 2022, the resident weighed 145.3 pounds, and then on June 8, 2023 the resident weighed 139.6 pounds, which was a 4% weight loss in six months.
Review of Resident 105's current care plan initially dated July 14, 2022, and revised May 31, 2023 indicated that the resident had a nutritional problem or potential nutritional problem related to a variable appetite, mild protein-calorie malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function), and altered skin integrity. The goal was for the resident to have no significant weight changes. Interventions included weights as ordered (monthly).
Further review of the clinical record at the time of the survey ending August 18, 2023, revealed no documented evidence that a monthly weight was obtained for the month of July 2023. The last weight obtained was on June 8, 2023.
Interview with the director of nursing on August 17, 2023 at 2:30 PM confirmed that there was no documented evidence that Resident 105's monthly weight was obtained to monitor for weight changes.
A review of Resident 9's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses which included hypertension and depression.
Further review of Resident 9's clinical record revealed the following weights
January 11, 2023 186.0 pounds
February 8, 2023 187.8 pounds
March 8, 2023 171.4 pounds 16.4 pound and 8.73% significant weight loss
April 8, 2023 174.8 pounds
May 11, 2023 173.4 pounds
June 8, 2023 174.0 pounds
There was no documentation a reweight was obtained after the March 8, 2023, weight of 171.4 pounds indicating a 16.4 pound and 8.73% significant weight loss as per the facility policy. There also was no indication that the physician was informed of the significant weight loss. There was no documentation that weights were obtained after June 8, 2023, as of the time of the survey ending August 18, 2023.
A review of Resident 106's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses which included mild protein calorie malnutrition and dementia.
Further review of Resident 106's clinical record revealed the following weights:
February 1, 2023 112.8 pounds
March 10, 2023 110.8 pounds
April 8, 2023 111.0 pounds
May 11, 2023 119.6 pounds 8.6 pound and 7.74% significant weight gain
June 5, 2023 108.0 pounds 11.6 pound and 9.69% significant weight loss
June 8, 2023 106.0 pounds
June 14, 2023 111.2 pounds
August 2, 2023 110.0 pounds
There was no documentation a reweight was obtained after the May 11, 2023, weight of 119.6 pounds indicating a 8.6 pound and 7.74% significant weight gain, and the June 5, 2023 weight of 108.0 pounds to be a 11.6 pound and 9.69% significant weight loss.
A physician note dated June 7, 2023, at 2:43 p.m. indicated that, she had weight loss, but seems weight of 119 on May 11, 2023 may be incorrect.
There was no documentation that weights were obtained in July 2023.
A review of Resident 55's clinical record revealed the resident was admitted to the facility on [DATE], and had diagnoses, which included heart disease.
Review of Resident 55's current care plan initially dated November 11, 2022, and revised June 12, 2023 indicated the resident has a nutritional problem or potential nutritional problem related to a heart disease, poor intakes, and diuretic use. The goal was for the resident to have no significant weight changes. Interventions included RD to evaluate and make diet change recommendations PRN and weights as ordered (monthly).
Further review of Resident 55's clinical record revealed the following weights
July 2, 2023 108.4 lbs.
August 2, 2023 96.4 lbs. 18 pounds and 11.07% significant weight loss
There was no documentation a reweight was obtained after the August 2, 2023, weight of 96.4 pounds indicating an 18 pound and 11.07% significant weight loss as per the facility policy. There also was no indication that the physician and resident representative were informed of the significant weight loss. Further review revealed that there was no documentation that the dietician responded timely, there was 14 days between the significant weight loss and the dietitian noting the resident's weight loss.
Interview with the Director of Nursing on August 17, 2023, at 2:10 p.m. she confirmed that the facility failed to consistently weigh residents at the planned frequency, timely re-weigh residents to verify signifcant weight changes, and promptly address signifcant weight loss.
28 Pa Code 211.12 (c)(d)(3)(5) Nursing services.
28 Pa Code 211.10 (a)(c)(d) Resident care policies.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to clinically justify the ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff interview, it was determined that the facility failed to clinically justify the use of duplicate drug therapy of an antidepressant medication for two out of 27 sampled residents (Resident 20 and 98).
Findings include:
A review of Resident 20's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included depression and anxiety.
The resident had current physician orders initially dated January 1, 2021, for Effexor (used to treat depression) 150 milligrams (mg) at 8:00 a.m., February 6, 2020 for Effexor 37.5 mg at 9:00 p.m. for depression, and January 1, 2021 for Sertraline (Zoloft- used to treat depression) 75 mg one time a day at 8:00 a.m. for depression.
A review of Resident 98's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included depression and anxiety.
The resident had current physician orders initially dated November 10, 2022, for Remeron (used to treat depression) 15 mg one time a day at 9:00 p.m. and November 11, 2022 for Zoloft (used to treat depression) 50 mg one time a day at 9:00 a.m. for depression.
The residents' clinical records failed to include documented physician resident-specific rationale of the clinical necessity of the duplicate drug therapy for treatment of Resident 20 and Resident 98's depression, which was confirmed during interview with the Director of Nursing on August 18, 2022 at 9:30 a.m.
28 Pa. Code 211.5 (f) Clinical records
28 Pa. Code 211.9 (a)(1)(k) Pharmacy services
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, review of the facility's menus, and staff interview, it was determined that the facility failed to follow the written menu as planned for resident meal service and failed to ensu...
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Based on observation, review of the facility's menus, and staff interview, it was determined that the facility failed to follow the written menu as planned for resident meal service and failed to ensure that fruit juices offered by the facility were provided as indicated on the menu to meet the nutritional needs of the resident.
Findings include:
Observation of the food and nutrition services department on August 15, 2023, at 9:15 AM revealed a juice and beverage dispensing system, which contained boxed juices and beverages that were connected to a dispensing system. The orange fruit juice-based beverage and apple fruit juice-based beverage, which were connected to the dispensing system were noted to be only 50 % fruit juice and other ingredients included high fructose corn syrup.
Interview with the foodservice director at this time confirmed that the orange fruit juice-based beverage and apple fruit juice-based beverage were offered as the facility's fruit juice on the facility's planned menu.
Observation of the facility's current menu revealed that 6 ounces of assorted juice was planned to be served every day for breakfast. Review of the facility's Menu and Diet Guidelines indicated to count fruit juice as one of the five fruits and vegetables required daily the juice offered needs to be 100% juice or juice blend.
Interview with the corporate certified dietary manager on August 17, 2023 at approximately 1:00 PM failed to provide documented evidence the facility provided 100% fruit juice or 100% juice blend at breakfast as planned on the facility menu.
28 Pa. Code 211.6 (a) Dietary services
Jul 2023
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility grievances, observation, and staff interview it was determined that the facility failed to provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of facility grievances, observation, and staff interview it was determined that the facility failed to provide housekeeping services to maintain a clean and orderly environment on five of five nursing units/floors (Aspen, Birch, Cypress, Pine, and Sycamore) including resident rooms (203, 209, 215, 216, 220, 232, 233, 236, 238, 244, 301, 309, 311, 315, 319, 320, 324, and 326).
Findings include:
A review of the facility's log of grievances and concerns lodged with the facility during the months of May 2023, June 2023 and July 2023 revealed that on May 20, 2023, and May 23, 2023, and June 19, 2023, concerns were reported to the facility regarding resident rooms being dirty, the entire 3rd floor had an odor of urine, the entire Aspen wing was always dirty and a resident bathroom not being cleaned.
During an environmental tour of the facility, 3rd floor - unit (Pine and Sycamore), on July 11, 2023, at approximately 9:35 AM, accompanied by Employee 2, Registered Nurse Supervisor, the following was observed and confirmed by Employee 2:
An accumulation of splattered food debris, brown, black, smears, red stains, salt packet, candy paper wrappers, plastic medication cups, was observed throughout the entire floor of the nursing units. Broken pretzels were observed on the floor near the nursing station and an pervasive urine-like odor permeated entire 3rd floor.
In resident rooms 301, 309, 311, 315, 319, and 326, brown, black, smears, red stains, and paper debris were observed on the floor.
On the floor of Resident room [ROOM NUMBER] a plastic-rubber resident identification wrist band was observed.
In resident room [ROOM NUMBER], brown, black, smears, and a straw were observed on the floor.
During an environmental tour of the facility, 2rd floor - unit (Birch, Cypress, and Aspen) on July 11, 2023, at approximately 9:55 AM, accompanied by Employee 3, Licensed Practical Nurse, the following was observed and confirmed by Employee 3:
An accumulation of splattered food and paper debris, brown, black, smears, and red stains, was observed throughout the entire floor of the nursing units.
In resident rooms 203, 209, 215, and 216, dark stains, and paper debris, were observed on the floor.
In resident room [ROOM NUMBER] a plastic medication cup, water spill, and brown, black smear were observed on the floor.
In resident room [ROOM NUMBER], paper debris and a surgical glove were observed on the floor.
In Resident rooms [ROOM NUMBER] dark smears and stains were observed on the floor.
In resident room [ROOM NUMBER], paper debris, stains, and a plastic soda bottle (cherry cola) were observed on the floor.
Interview with the Nursing Home Administrator (NHA) on July 11, 2023, at approximately 1:05 P.M., confirmed the resident environment was to be maintained in a clean, safe, and orderly manner.
28 Pa. Code 201.18 (e)(2.1) Management
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observations during a tour of the dietary department and staff interview, it was determined that the facility failed to maintain acceptable food services sanitation practices for the preparat...
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Based on observations during a tour of the dietary department and staff interview, it was determined that the facility failed to maintain acceptable food services sanitation practices for the preparation and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness.
Findings include:
Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).
During a tour of the dietary department on July 11, 2023, at approximately 10:15 A.M., with Employee 4 (Dietary Supervisor), the following sanitation issues, with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified and confirmed:
There were multiple loose, crumbling, and/or missing tiles along several walls outside the dish machine area exposing the wall particle board.
The ceiling tiles and the ceiling vent, located adjacent to the steam table-tray line (the area where hot food is plated during meals), were covered with an accumulation of grease, lint and dirt. The ceiling tile connecting metal spacers, located directly over the steam table - tray line, was also coated with the same greasy debris.
There was black dark substance located along the wet backsplash on the wall near the dish machine.
Interview with the Nursing Home Administrator on July 11, 2023, at 1:05 PM, confirmed that the dietary department was to be maintained in a sanitary manner.
28 Pa. Code 211.6 (f) Dietary services.
28 Pa Code 201.18(e)(2.1) Management
Mar 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
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 timely obtain prescribed labor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview it was determined that the facility failed to timely obtain prescribed laboratory services for one resident out of eight residents sampled (Resident A1).
Findings included:
A review of clinical record revealed Resident A1 was admitted to the facility on [DATE], with diagnoses, which included anxiety and dementia with behavioral disturbance.
According to the clinical record the resident had a change in condition, that required an evaluation in the emergency room on October 28, 2022. The resident returned to the facility that same day with a diagnosis of acute cystitis and orders for antibiotic therapy.
Nursing documentation dated March 17, 2023, at 1:41 PM indicated that Resident A1 was screaming at staff and other residents, demanding she gets a ride home. Staff attempts at redirection were unsuccessful. According to the nursing documentation, the physician ordered a U/A and C&S (urinalysis, culture and sensitivity), and the resident's daughter was made aware of the new physician order.
Nursing noted March 17, 2023, at 9:43 PM, that staff were unable to obtain the urine specimen to conduct the ordered lab testing.
Nursing documentation dated March 19, 2023, at 9:40 PM, indicated that staff were unable to obtain the urine specimen and that the patient incontinent and refused straight cath (one time catheterization for specimen).
At time of survey ending on March 28, 2023, there was no documented evidence that the facility nursing staff had notified the prescribing practitioner that the resident refused straight catheterization and that the nursing staff could not obtain a urine sample to complete the required diagnostic lab testing.
During an interview with on March 28, 2023, at approximately 2:15 PM the Nursing Home Administrator confirmed that the lab studies were not completed timely as ordered.
28 Pa. Code 211.12(a)(c)(d)(3)(5) Nursing services
Feb 2023
6 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0567
(Tag F0567)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select investigative reports and information submitted by the facility and staff interview,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records, select investigative reports and information submitted by the facility and staff interview, it was revealed that the facility failed to provide evidence that the resident was afforded the opportunity to deposit funds greater than $100 into an interest-bearing account for one resident out of 9 sampled and assure an effective and functional system was in place to safeguard against any misappropriation of a resident's funds (Resident CR2)
Findings include:
A review of Resident CR2's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses which included hypertension and post-surgical healing of the left lower extremity.
Review of inventory sheet dated January 10, 2023, revealed that the resident had a total of $2,661.60 cash in his possession. According to the inventory sheet, the facility's business office manager provided the resident a receipt for the cash and placed it in the facility's safe. The facility failed to document the date and time the funds were received from the resident when residents make requests that the facility temporarily place their funds in a safe place, without authorizing the facility to manage those funds.
There was no evidence that the resident was afforded the opportunity to deposit his personal funds in a interest-bearing account for the duration of his stay at the facility.
A review of a facility investigation and a Pennsylvania Department of Health, PB-22 report form for investigation of alleged abuse, neglect or misappropriation dated February 13, 2023, at 12:00 PM revealed that on February 11, 2023, Resident CR2 was being discharged home with family and was to be given approximately $2,600 cash which was being stored in the facility's safe for the resident.
On February 11, 2023, the weekend receptionist and Human Resource Director opened the safe to give Resident CR2 his money upon discharge from the facility. There was only $200 of the reported $2,600 in the safe.
An investigating was initiated. Employee 1, former housekeeper, was identified on facility camera footage entering the front entrance to the facility at 1:30 AM on February 11, 2023. Employee 1 was then observed entering the office area where the safe was located and exiting the facility approximately 4 minutes later. A review of employee badge swipes further confirmed that Employee 1 entered the facility at 1:30 AM on February 11, 2023.
According to the facility investigation, Employee 1 was in a relationship with a facility receptionist who knew that the money was placed in the safe the day prior to discharge. The police, AAA, and the resident's representative were notified.
Interview with the Nursing Home Administrator on February 27, 2023, at 9:28 AM, revealed that as of January 9, 2023, Employee 1 resigned from employment with the facility's contracted housekeeping agency. According to the NHA, the contracted agency failed to notify the facility that Employee 1 was no longer employed, therefore, his badge which allowed him access to the facility was not disabled.
The NHA further stated that on February 10, 2023, Resident CR2's cash totaling approximately $2,600 was moved from the facility's safe which was maintained in the business office, out to the petty cash safe located in the reception office. The money was moved in preparation for the resident's discharge on Saturday, February 11, 2023. According to the NHA, the petty cash safe can be accessed via a keypad code by administrative staff, including the receptionist. The receptionist on duty has keys to access the reception area and other areas of the facility. According to the NHA, there was no system in place to ensure that those keys were kept at the facility when there was no receptionist on duty.
Interview with the Nursing Home Administrator on February 27, 2023, at 1:30 PM confirmed that there was no evidence that the resident was offered the opportunity to deposit the $2,661.60 he brought into the facility into an interest-bearing account for the duration of his stay. The resident's funds were subsequently misappropriated and the facility failed to implement an effective system to safeguard personal funds held by the facility.
Refer F 602
28 Pa Code 201.18 (e)(1)(f)(h) 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
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on a review of clinical records, select facility policy, investigative reports and information submitted by the facility and staff interview, it was determined that the facility failed to ensure...
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Based on a review of clinical records, select facility policy, investigative reports and information submitted by the facility and staff interview, it was determined that the facility failed to ensure are resident was free from misappropriation of resident property (money) for one resident (Resident CR2) out of 9 sampled.
Findings include:
The facility policy for Abuse Prevention, provided by the facility during the survey of February 27, 2023, revealed that residents have the right to be free from abuse, neglect, misappropriation of the resident property and exploitation. As part of the resident abuse prevention, the administration will implement the following protocols: protect resident from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals.
Review of personal inventory sheet dated January 10, 2023, revealed Resident CR2 had a total of $2,661.60 cash in his possession upon admission to the facility. According to the resident's personal inventory sheet, the facility's business office manager provided the resident a receipt and placed the resident's money was placed in the facility's safe.
A review of a facility investigation and a Pennsylvania Department of Health, PB-22 report form for investigation of alleged abuse, neglect or misappropriation dated February 13, 2023, at 12:00 PM revealed that on February 11, 2023, Resident CR2 was being discharged home with family and the approximately $2,600 cash which was being stored in the facility's safe was to be dispersed to the resident.
However, on February 11, 2023, the weekend receptionist and Human Resource Director opened the facility safe to give Resident CR2 his money upon discharge from the facility, but there was only $200 of the reported $2,600 cash in the safe. An investigation into the resident's missing money was initiated. Employee 1, a former facility housekeeper, was seen on the facility's surveillance camera footage entering the front entrance to the facility at 1:30 AM on February 11, 2023. Employee 1 was then observed entering the office area where the safe was located and exiting the facility approximately 4 minutes later. A review of employee badge swipes further confirmed that Employee 1 entered the facility at 1:30 AM on February 11, 2023.
According to the facility's investigation, Employee 1 was in a relationship with a facility receptionist who knew that the resident's money was placed in the safe the day prior to discharge. The police, AAA, and the resident's representative were notified.
Interview with the Nursing Home Administrator on February 27, 2023, at 9:28 AM, revealed that as of January 9, 2023, Employee 1 resigned from employment with the facility's contracted housekeeping agency. According to the NHA, the contracted agency failed to notify the facility that Employee 1 was no longer employed, therefore, his badge, which allowed him access to the facility, was not disabled.
The NHA further stated that on February 10, 2023, Resident CR2's cash totaling approximately $2,600 was moved from the facility's safe, which was maintained in the business office, out to the petty cash safe located in the reception office. The money was moved in preparation for the resident's discharge on Saturday, February 11, 2023. According to the NHA, the petty cash safe can be accessed via a keypad code by administrative staff, including the receptionist. The receptionist on duty has keys to access the reception area and other areas of the facility. According to the NHA, there was no system in place to ensure that those keys were kept at the facility when there was no receptionist on duty.
The facility reimbursed Resident CR2 and a police investigation in Employee 1's misappropriation of Resident CR2's money was ongoing at the time of survey ending February 27, 2023.
During an interview on February 27, 2023, at approximately 10:30 AM, the Nursing Home Administrator confirmed the misappropriation of Resident CR2's personal property.
Refer F567, F607
28 Pa. Code 201.29(a)(c) Resident rights
28 Pa. Code 201.18 (e)(1) Management
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 a review of the facility's abuse policy and employee personnel files and staff interviews, it was determined that the f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's abuse policy and employee personnel files and staff interviews, it was determined that the facility failed to implement their established procedures for screening one of two employees for employment (Employee 1).
Findings include:
The facility's Abuse Prevention Program policy provided by the facility during the survey of February 27, 2023, revealed that the facility residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. As part of the resident abuse prevention, the administration will implement the following protocols: protect residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Conduct employee background checks and will not knowingly employ or otherwise engage any individual who has been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law.
In accordance with Act 13 Elder Abuse Mandatory Reporting and Act 169 Criminal Background Checks, nursing facilities are required to obtain a criminal background check on all newly hired employees. Facilities are required to obtain the Pennsylvania State Police background check within 30 days of hire on all prospective employees. If the prospective employee does not have continuous residency in Pennsylvania for two years prior to employment, then the facility is required to obtain a Federal Bureau of Investigation (FBI) check within 90 days.
Employee 1, housekeeper, was hired by the facility's contracted housekeeping services on October 7, 2022. A Pennsylvania State Police background check was obtained on September 1, 2022.
Review of Employee 1's application for employment revealed that his previous employer let him go. Employee 1 worked for the employer from 2020 to an undetermined date, the area of the application was left blank. The reference section of application did not provide a name, just a phone number, and the address was [NAME], New York. The confidential reference check completed for Employee 1 was completed with an employer that was not identified on employment application. There was no name provided of the reference obtained, and the question was the employee ever disciplined or terminated because of an incident(s) involving violent behavior in the workplace, or abuse, neglect, or mistreatment towards patients/clients/residents? was left unanswered.
Further review of Employee 1's personnel file revealed that a Pennsylvania Identification Card was issued on February 20, 2021, and there was no documented evidence that the employee had been a continuous resident of the state of Pennsylvania for the last 2 years.
Interview with the Human Resources Director (HR) on February 27, 2023, at 12:46 PM, confirmed that the Employee 1's application for employment failed to provide evidence that Employee 1 had been a continuous resident of the state of Pennsylvania for the last 2 years and therefore the employee required an FBI background check.
Interview with the Nursing Home Administrator on February 27, 2023, at approximately 2:30 PM, confirmed that based on the information provided in Employee 1's application, an FBI background check should have been completed and the employee's screening was incomplete.
Refer F602
28 Pa Code 201.18 (e)(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
Deficiency F0660
(Tag F0660)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff it was determined that the facility failed to develop and implement an individua...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff it was determined that the facility failed to develop and implement an individualized discharge plan for one of nine residents reviewed (Resident CR1) to reflect the resident's discharge goals.
Findings Include:
Clinical record review revealed that Resident CR1 was admitted to the facility on [DATE], and was discharged to home with family on February 18, 2023.
A review of the resident's care plan, initially dated January 23, 2023, revealed that the resident wished to return home where she lived with son and daughter-in-law. Interventions planned to meet this goal included conducting an evaluation of the resident's motivation to return to the community, make arrangements with required community resources to support independence post-discharge as needed, encourage the resident to discuss feelings and concerns with impending discharge, and that the resident had ramp access at sister's residence with no home health preference.
Review of an admission Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated January 25, 2023, indicated the resident was severely cognitively impaired and required staff assistance with activities of daily living which included dressing, toilet use, and bed mobility.
Resident CR1's representative submitted a concern on February 20, 2023, that the resident was discharged from the facility with a referral for in-home health care, but given no details. The resident's representative further indicated that the resident was discharged without supplies or instructions to care for the ulcer that developed on the resident's heel at the facility.
Review of Resident CR1's clinical record revealed Social Service documentation dated February 17, 2023, at 2:03 PM, which indicated that the resident's last covered day was February 17, 2023, and the son requested resident to return home February 18, 2023. According to the social service documentation, the resident was being discharged with home health services, but did not identify if services were arranged or simply a referral made for those services. A wheelchair was also being ordered and was to be delivered to the resident's home.
Further review of the resident's clinical record failed to provide evidence that additional discharge instructions and/or information was provided to the resident's family to prepare the resident's family for the resident's discharge. There was no indication that discharge instructions regarding use of prescribed medications or treatment to resident's heel ulcer were provided to the family.
Interview with the Nursing Home Administrator on February 27, 2023, at approximately 1:30 PM revealed that each resident was to be provided with a Discharge Instructional Packet on day of discharge, but was unable to confirm that Resident CR1's family had been provided this packet. The discharge instructional packet provides information from each interdisciplinary team member that participated in the resident's care. The packet includes information regarding the resident's discharge plan, community resource guide, functional mobility, nutrition, activities, continence, a summary of the resident's stay, medication tips and treatments, medication information, and a signed copy of the resident's inventory sheet. A copy of the discharge packet is to be kept with the medical record and the original is to be given to the resident upon discharge.
The NHA confirmed during interview on February 27, 2023, at 1:30 PM that there was no evidence that the instructional packet was provided to Resident CR1's family upon discharge. The administrator further confirmed that there was no evidence that the resident's family was provided medication and/ or treatment instructions for the resident's heel ulcer.
28 Pa. Code 201.25 Discharge policy
28 Pa. Code 211.11 (d)(e) Resident care plan
28 Pa. Code 211.16 (a) Social Services
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 staff and interview it was determined that the facility failed to provide services necessary...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff and interview it was determined that the facility failed to provide services necessary to maintain adequate personal hygiene and/or grooming of one resident, dependent on staff for assistance with bathing, out of nine sampled residents (Resident CR1).
Findings include:
Review of the current facility policy entitled Bath/Shower/Tub, provided by the facility during the survey of February 27, 2023, revealed that if a resident refused the shower/tub bath, staff are to document the reason(s) why and the intervention taken. Additionally, staff are to notify the supervisor if the resident refuses the shower/tub bath.
A review of Resident CR1's clinical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, and surgical repair of left leg fracture after a fall at home.
Review of hospital discharge instructions dated January 19, 2023, revealed that the resident had a surgical incision with staples intact. According to the incisional instructions, the resident may shower and let water run over the staples.
Review of an admission Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process completed at specific intervals to plan resident care) dated January 25, 2023, indicated that the resident was severely cognitively impaired and required staff assistance with activities of daily living which included dressing, toilet use, bathing, and personal hygiene.
Review of Resident CR1's Documentation Survey Report dated January 2023, revealed that the resident was scheduled to receive a shower on the 3 PM to 11 PM shift every Sunday and Wednesday. According to the report, the resident refused a shower each evening it was scheduled during the month of January 2023. There was no documented evidence that the resident was showered during the month of January 2023.
Review of Resident CR1's Documentation Survey Report dated February 2023, revealed that the resident was provided a shower on February 1, 2023. According to the report, the resident refused a shower on February 5, 2023, received a bed bath on February 8, 2023, refused a shower on February 12, 2023, and the resident's scheduled shower was noted NA (not applicable) on February 15, 2023.
The resident's care plan, initiated February 17, 2023, one day prior to the resident's discharge from the facility, revealed a focus that the resident was resistive to care related to showering with a goal for resident to be cooperative with care through next review date. Interventions were to include to allow the resident to make decisions about treatment regimen, to provide sense of control, encourage as much participation/interaction by the resident as possible during care activities, educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care, if possible, negotiate a time for ADLs so the resident participates in the decision making process, return at the agreed upon time, if resident resists with ADLs, reassure resident, leave and return 5-minutes later and try again.
Interview with the Nursing Home Administrator on February 27, 2023, at approximately 11:00 AM confirmed that there was no evidence that the facility staff made additional attempts to shower the resident, including offering an alternate day or shift. There was no indication that the staff reported the resident's refusals to the supervisor, or if any additional interventions were timely developed and attempted to provide the resident with a shower during her stay at the facility to ensure adequate personal hygiene.
Refer F686
28 Pa. Code 211.12 (a)(c)(d)(1)(5) Nursing services.
28 Pa. Code 201.29 (j) Resident rights
28 Pa. Code 211.10(a)(d) Resident care policies
28 Pa. Code 211.11 (d) Resident care plan
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy, and staff interviews it was determined that the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and select facility policy, and staff interviews it was determined that the facility failed to consistently provide necessary care and services to prevent the development of a pressure sore for one resident (Resident CR1) out of 9 sampled residents.
Findings include:
According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk.
ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.
Review of current facility policy entitled Pressure Ulcers/Skin Breakdown- Clinical Protocol, provided by the facility during the survey on February 27, 2023, revealed that the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes, congestive heart failure, over medical instability, cancer or sepsis causing a catabolic state, and macerated or friable skin.
A review of the clinical record revealed that Resident CR1 was admitted to the facility on [DATE], with diagnoses to include diabetes, dementia, hypertension, and post-surgical repair of a fractured left hip after a fall at home. The resident also utilized bilateral leg braces for ambulation.
Review of hospital discharge instructions dated January 19, 2023, revealed that the incision was closed with staples, which would be taken out at the resident's post operative appointment. The orthopedic surgery office was to be called immediately if there was increased redness, swelling, or pus drainage from the incision. A dressing over the incision may be applied for comfort, for example, if the staples catch on clothes, otherwise leave incision open to air.
A review of an admission Minimum Data Set assessment dated [DATE], (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed that the resident was severely cognitively impaired, required extensive assistance with the assistance of two people with bed mobility (how the resident moves about in bed), required extensive assistance of one staff member transferring (how the resident moves between the bed and the chair), toilet use, and personal hygiene. The resident had a surgical wound and was at risk for pressure ulcer development.
There was no documented evidence in the resident's clinical record that an admission skin evaluation was completed by the facility's licensed and professional nursing staff. There was no documented evidence that the resident's surgical incision with staples, as noted in hospital discharge instructions, was evaluated or monitored by licensed and professional nursing staff for increased redness, swelling, or drainage throughout the resident's stay at the facility.
Review of Resident CR1's skin evaluation dated February 15, 2023, at 10:10 PM, indicated that the resident had no skin issues. There was no documented evidence in the clinical record that a skin evaluation was completed prior to February 15, 2023.
Review of resident skin evaluation dated February 16, 2023, at 11:39 PM, revealed that the resident developed an unstageable pressure ulcer injury on the left heel. According to the evaluation, the wound bed was necrotic (dead tissue), there was no drainage, and the resident was free from pain related to the ulcer.
A review of the resident's plan of care for potential/actual skin impairment related to surgical wound initially dated January 20, 2023, revealed planned interventions that included to avoid scratching and keep hands and body parts from excessive moisture, keep fingernails short, encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of injury, pressure reducing mattress, pillows, to protect skin while in bed, and pressure reducing cushion to protect the skin while up in chair.
There was no documented evidence that pressure reducing devices were in place on the resident's bed and chair for the months of January 2023 or February 2023.
The facility was unable to demonstrate that the development of the resident's left heel pressure ulcer was unavoidable based on the lack of documented evidence of interventions to prevent skin breakdown despite the resident's risk for pressure ulcer development.
Interview with the Nursing Home Administrator on February 27, 2023, at approximately 2:45 PM confirmed the facility failed to demonstrate the implementation of measures to prevent the development of pressure ulcers for resident with identified skin concerns and at risk for skin breakdown.
Refer F677
28 Pa. Code 211.12(a)(c)(d)(1)(3)(5) Nursing services.
28 Pa. Code 211.5(f)(g)(h) Clinical records.
28 Pa. Code 211.10(a)(d) Resident care plan
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, Payment denial on record. Review inspection reports carefully.
- • 78 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade F (20/100). Below average facility with significant concerns.
- • 57% 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.
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About This Facility
What is River View's CMS Rating?
CMS assigns RIVER VIEW NURSING AND REHABILITATION CENTER an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Pennsylvania, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is River View Staffed?
CMS rates RIVER VIEW NURSING AND REHABILITATION CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 57%, which is 11 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 57%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at River View?
State health inspectors documented 78 deficiencies at RIVER VIEW NURSING AND REHABILITATION CENTER during 2023 to 2025. These included: 76 with potential for harm and 2 minor or isolated issues. While no single deficiency reached the most serious levels, the total volume warrants attention from prospective families.
Who Owns and Operates River View?
RIVER VIEW NURSING AND REHABILITATION CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by IMPERIAL HEALTHCARE GROUP, a chain that manages multiple nursing homes. With 180 certified beds and approximately 119 residents (about 66% occupancy), it is a mid-sized facility located in WILKES BARRE, Pennsylvania.
How Does River View Compare to Other Pennsylvania Nursing Homes?
Compared to the 100 nursing homes in Pennsylvania, RIVER VIEW NURSING AND REHABILITATION CENTER's overall rating (1 stars) is below the state average of 3.0, staff turnover (57%) 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 River View?
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 River View Safe?
Based on CMS inspection data, RIVER VIEW NURSING AND REHABILITATION CENTER has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). 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 River View Stick Around?
Staff turnover at RIVER VIEW NURSING AND REHABILITATION CENTER is high. At 57%, the facility is 11 percentage points above the Pennsylvania average of 46%. Registered Nurse turnover is particularly concerning at 57%. 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 River View Ever Fined?
RIVER VIEW NURSING AND 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 River View on Any Federal Watch List?
RIVER VIEW NURSING AND REHABILITATION CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.