Pennsylvania Department of Health
EMERALD NURSING AND REHABILITATION
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

EMERALD NURSING AND REHABILITATION
Inspection Results For:

There are 140 surveys for this facility. Please select a date to view the survey results.

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EMERALD NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed May 22, 2025, it was determined Emerald Nursing and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

483.25(l) REQUIREMENT Dialysis:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

§483.25(l) Dialysis.
The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Observations:

Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences, for one of one resident reviewed for dialysis (Resident 23).

Findings Include:

Review of facility policy, titled "End Stage Renal Disease, Care of a Resident with," last reviewed on March 31, 2025, read, in part, "Residents with end stage renal disease (ESRD) will be cared for according to currently recognized standards of care. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. Education and training of staff includes, specifically: the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care."

Review of Resident 23's clinical record revealed diagnoses that included ESRD (failure of kidney function to remove toxins from blood) and dependence on renal dialysis (an artificial process for removing waste products and excess fluids from the body that is needed when the kidneys are not functioning properly).

Review of Resident 23's clinical record revealed she has been receiving dialysis treatments since 2022, and revealed an active physician order for dialysis three times per week at an outside facility.

Further review of Resident 23's physician orders revealed an active order for "Dialysis Precautions: No blood draws, injections, or blood pressure from left arm."

Review of Resident 23's comprehensive care plan revealed an active focus area for "renal insufficiency" (compromised kidney function) with an intervention for, "Do not take blood pressure or blood specimens from left arm" and "coordinate dialysis care with the dialysis treatment facility."

Review of Resident 23's blood pressure measures revealed it was documented that they were taken in the left arm nine times since July 12, 2024

Review of select dialysis communication forms (a form utilized to facilitate communication of assessment data between a dialysis center and a nursing care facility), revealed none were provided for the following dates that Resident 23 attended dialysis: February 5 and 12, 2025; March 5, 12, 19, and 26, 2025; April 9, 11, 18, 21, 23, 25, 28, and 30, 2025; and May 5, 7, 9 and 12, 2025.
.
During an interview with the Director of Nursing on May 21, 2025, at 10:19 AM, she revealed the blood pressures that were documented in the left arm were likely documentation errors, however, staff education will be implemented to ensure blood pressures are not taken in Resident 23's left arm. She further revealed she was unable to locate the missing dialysis communication forms from Resident 23's clinical record, and she would expect them to be completed and available for review.

28 Pa Code 211.5(f) Medical records
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/09/2025

1) Educated the Nursing Professional and CNAs to not take the blood pressure in the left arm.

2) Reviewed dialysis residents to ensure blood pressure was taken on the correct arm.

3) Reeducated Nursing Professionals and CNAs about F0698 and the need to recognize the arm for blood pressure application when dialysis ports are in place.

4) Director of Nursing or designee will audit blood pressure documentation for dialysis residents 3 x a week for 3 months. These audits will be reviewed at QAPI

483.75(g)(1)(i)-(iii)(2)(i); 483.80(c) REQUIREMENT QAA Committee:

§483.75(g) Quality assessment and assurance.
§483.75(g) Quality assessment and assurance.
§483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of:
(i) The director of nursing services;
(ii) The Medical Director or his/her designee;
(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and
(iv) The infection preventionist.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:
(i) Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects required under the QAPI program, are necessary.

§483.80(c) Infection preventionist participation on quality assessment and assurance committee.
The individual designated as the IP, or at least one of the individuals if there is more than one IP, must be a member of the facility's quality assessment and assurance committee and report to the committee on the IPCP on a regular basis.

Observations:

Based on review of select facility documentation provided and a staff interview, it was determined that the required members of the facility's Quality Assurance Committee failed to meet on a quarterly basis for two quarters of four reviewed (last quarter of 2024 and first quarter of 2025).

Findings include:

Review of the facility's Quality Assurance Committee meeting signatory pages revealed that the required members of the facility's Quality Assurance Committee, including the Medical Director (MD) or designee, the Nursing Home Administrator (NHA), and the Director of Nursing (DON), did not have a meeting where they were all in attendance, during the last quarter of year 2024 (October, November, and December).

Review of the facility's Quality Assurance Committee meeting signatory pages revealed that the required members of the facility's Quality Assurance Committee, including the MD or designee, the NHA, and the DON, did not have a meeting where they were all in attendance, during the first quarter of year 2025 (January, February, and March).

During an interview with the NHA on May 21, 2025, at 11:22 AM, she confirmed that it was the facility's expectation that the required members of the Quality Assurance Committee meet at least once every quarter.

28 Pa code 201.18(b)(1) Management

Plan of Correction - To be completed: 07/09/2025

1)The facility cannot retroactively correct the quarterly QAPIs that did not indicate participation by the Medical Director.

2) The facility checked current QAPI and Medical Director Administration for participation in QAPI.

3) Administration and Medical Director Team reeducated about F0868 and the need to participate in facility QAPIs minimally quarterly.

4) Administrator or designee will audit this quarterly to ensure that Medical Director participates in the QAPIs for the next year. These audits will be reviewed at QAPI.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on facility policy review, observations, and staff interview, it was determined that the facility failed to store food and beverages and utilize kitchen equipment in accordance with professional standards for food service safety in the main kitchen.

Findings include:

Review of facility policy, titled "Food Storage" last reviewed March 31, 2025, read, in part, "It is the policy of this facility that food storage areas be maintained in a clean, safe, and sanitary manner. Food storage areas should be clean at all times. All perishable food items shall be labeled with the name of the product and an 'opened date' after opening product. Food items should be closed to air to prevent decline of quality in product and cross contamination. Open should be discarded after 5 days. A food storage audit shall be conducted on a weekly basis by dietary manager or designee. All expired foods shall be discarded immediately upon finding. Scoops are not to be stored in containers with food products such as flour, sugar, and thickener, etc. Scoops are to be stored in a separate container with a lid or in a closed Ziploc bag. All scoops are to be washed on a weekly basis or when product is switched out."

Observation in the dry storage area on May 19, 2025, at 10:13 AM, revealed one bottle of honey thick orange juice with a best by date of January 6, 2025.

Observation in the reach-in freezer in the dry storage area on May 19, 2025, at 10:16 AM, revealed two packs of waffles not labeled with the name of the product or use by date; two open packages of waffles not labeled with the name of the product or an open date; and one pack of fish patties open, not labeled with the name of the product or an open date, and left open to air.

Observation in the main kitchen on May 19, 2025, at 10:17 AM, revealed one container of flour with a scoop stored inside; and one container of sugar with a scoop stored inside.

Observation in the milk reach-in refrigerator on May 19, 2025, at 10:18 AM, revealed two containers of milk with a sell by date of May 16, 2025, and a water bottle and a soda bottle belonging to kitchen staff members.

Further observation in the milk reach-in refrigerator on May 19, 2025, at 10:19 AM, revealed the bottom of the refrigerator was heavily soiled with liquid and dried milk.

Interview with the Nursing Home Administrator on May 21, 2025, at 10:12 AM, revealed it was the facility's expectation that expired items are discarded, foods items are labeled and dated per facility policy, and food items and kitchen equipment are stored, cleaned, and utilized in accordance with professional standards.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.6(f) Dietary services

Plan of Correction - To be completed: 07/09/2025

)a)Honey Thick orange juice with a best date of Jan 6, 2025, was immediately discarded.
b) Two packs of waffles that were not labeled, two open packages of waffles not labeled and open and the one pack of fish patties were immediately disposed.
c) The container of flour had the scoop removed immediately. The sugar container had the scoop removed immediately.
d) Two containers of milk in reach in refrigerator with past sell by dates was immediately discarded.
e) Water and soda bottle belonging staff were immediately discarded.
f) The bottom of reach in refrigerator was cleaned immediately.

2) Food storage has been reviewed for proper and storage and cleanliness with the dietitian.

3) Reeducated dietary staff and dietary director on F0812. Reset in place weekly audit of these areas.

4) Dietary director or designee will audit food storage areas weekly for three months. These audits will be reviewed at QAPI.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On:

§483.45(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.

Plan of Correction - To be completed: 07/09/2025

1) Ensured Resident 14, 23, 30 and 46's record was reviewed currently by the Consultant Pharmacist.
2) Residents reviewed for current review by the Consultant Pharmacist
3) Nursing administration, physicians, and consultant pharmacist reeducated about F0756 and the need to review resident's record by the Consultant Pharmacist.
4) Director of Nursing or designee will audit monthly to ensure the receipt of the Consultant Pharmacist report for 3 months. These audits will be reviewed at QAPI.
F0804

483.35(e)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:

§483.35(e)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).

Observations:

Based on review of select facility documentation and staff interview, it was determined that the facility failed to ensure that nurse aide performance evaluations were completed at least once every 12 months for four of five nurse aides reviewed (Employee 7, 8, 9, and 10).

Findings include:

Review of select facility documentation revealed a list of nurse aides that had worked at the facility for greater than a year; Employees 6, 7, 8, 9, and 10 were selected from the list to review their last annual nurse aide performance evaluations.

During an interview with the Director of Nursing on May 22, 2025, at 9:54 AM, she revealed she was unable to locate annual evaluations in the past 12 months for Employees 7, 8, 9, and 10; and she would expect them to be available and located in their employee files.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1) Management

Plan of Correction - To be completed: 07/09/2025

1)Employee evaluations 7, 8, 9, and 10 were redone.

2) Certified Nursing Assistants over a year in service reviewed for yearly evaluation completion

3) Nursing administration and Scheduler/HR reeducated about F 0730 and the need to have the yearly evaluations done.

4) Scheduler/HR will audit monthly the CNA evaluations for completion for three months. These audits will be reviewed at QAPI.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.

Observations:
Based on clinical record review, resident, and staff interviews, it was determined the facility failed to ensure each resident is treated with dignity and care in a manner and environment that maintains and enhances his or her quality of life for one of 16 residents (Resident 166).

Findings include:

Review of Resident 166's clinical record revealed diagnoses that included heart failure (the heart can't pump enough blood to meet the body's needs) and chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood).

During an interview with Resident 166 on May 19, 2025, at 10:12 AM, she revealed that she is continent of her bladder, however, due to long call bell wait times she has had several accidents, especially when she first arrived at the facility. Resident 166 revealed that she was embarrassed when she did not receive assistance to make it to the bed pan in time.

Review of the facility's Resident Council Meeting Minutes for May 2025 revealed Resident concerns with long call bell wait times.

Review of Resident 166's clinical record revealed she was admitted to the facility on May 14, 2025. Further review of Resident 166's admission assessment completed on May 15, 2025, revealed that she is continent of bladder.

Review of Resident 166's clinical record urinary continence task revealed that Resident 166 was marked as being incontinent the entire day on May 15, 16, and 17, 2025.

During an interview with the Director of Nursing (DON) on May 22, 2025, at 10:12 AM, she revealed that she spoke to the staff working May 15-17, 2025, with Resident 166 who said Resident 166 was constantly ringing their call bell to go to the restroom, however, it was not reflected in her clinical record. The DON revealed that she would expect staff to document every time Resident 166 was continent or incontinent.

28 Pa. Code 201.29 (j) Resident rights
28 Pa. Code 211.12 (d) (2) Nursing services

Plan of Correction - To be completed: 07/09/2025

Preparation and submission of the plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.

1) Center cannot retroactively correct this situation. Call Bell for this room checked for operational function. Resident reeducated about how to further address this issue.

2) Call Bells in center checked for operational function. Residents in the center audited regarding dignity with call bell answering.

3) Added to monthly maintenance checks the check of the call bells. Reeducated center staff on the importance of answering call bells and not turning them off if the need is not addressed.

4)) The department management team will audit the call bell answering 3 x a week and 1 x a weekend rotation. This will be on varied shifts for thirty days. On the spot education will be done by this team at the time of audit if there is no compliance with the response. These audits will be reviewed at QAPI.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:

Based on review of facility meal assessment form, completion of one meal test tray, and resident and staff interviews, it was determined that the facility failed to provide coffee that was at a palatable and appealing temperature.

Findings include:

Review of document, titled "Food and Nutrition Services Meal Assessment" last revised November 1, 2011, revealed coffee should have a temperature of 135 degrees Fahrenheit (F) or above at the time of service.

Interview with Resident 24 on May 19, 2025, at 12:36 PM, revealed the coffee provided by the facility is never served hot.

A test tray was completed on May 21, 2025, at 12:11 PM, upon the completion of lunch meal service with Employee 11 (Food Service Director). Employee 11 took the temperature of the coffee on the test tray as 110 degrees F, the coffee was not palatable or appealing to drink.

Interview with Employee 11 on May 21, 2025, at 12:13 PM, revealed coffee should be poured and lidded between 5-10 minutes prior to meal service to ensure it stays hot to meet the minimum acceptable temperature at point of service; and that it was likely that the kitchen staff had poured the coffee too early that day.

Interview with the Nursing Home Administrator on May 21, 2025, at 1:56 PM, revealed she would expect coffee to be served to residents at palatable and appealing temperatures.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 07/09/2025

1) Coffee that did not meet palatable temps was removed and replaced with acceptable coffee.

2) Coffee temp before tray line will be monitored for 2 weeks for baseline.

3) Reeducated the dietary staff and director on F0804 and appropriate coffee temps. New protocol was developed for coffee delivery.

4) Dietary Director or designee will audit coffee temperatures daily for sixty days. These audits will be reviewed QAPI.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(f). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to implement procedures to ensure availability of prescribed medications for one of 16 Residents reviewed (Resident 166).

Findings include:

Review of Resident 166's clinical record revealed diagnoses that included heart failure (the heart can't pump enough blood to meet the body's needs) and chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood).

Review of Resident 166's clinical record revealed she was admitted to the facility on May 14, 2025.

Review of Resident 166's May 2025 Medication Administration Record (MAR) revealed she had an order for Furosemide Oral Tablet 40 milligrams (mg), give one tablet by mouth one time a day for chronic heart failure, with a start date of May 15, 2025. Further review of Resident 166's May 2025 MAR revealed that the order was blank from May 15-18, 2025, indicating she did not receive the medication on those days.

During an interview with the Director of Nursing (DON) on May 22, 2025, at 10:14 AM, she confirmed Resident 166 did not receive her medication on those days and revealed that when Resident 166 was admitted to the facility, agency staff were working and did not have access to the online system to pull the medication as ordered by the physician. The DON revealed that she would have expected Resident 166 to have received her medication as ordered.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/09/2025

1) The facility cannot retroactively correct the missed furosemide for Resident 166. There were no ill effects from Resident 166 missing this medication.

2) Residents who take furosemide had their medication administration reviewed from admission.

3) Nursing professionals reeducated about F0755 and the need to make sure that furosemide is given according to orders. Nursing on Call setup to respond to need to retrieve medications from the online system if there are no facility staff present to support agency needs with medication administration.

4) Director of Nursing or designee will audit the furosemide medication administration of the new admissions for three months. These audits will be reviewed at QAPI.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies:

§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Observations:

Based on facility policy review, personnel file reviews, and staff interview, it was determined that the facility failed to implement written policies and procedures by not conducting a criminal background check upon hire for two of five personnel files reviewed (Employees 4 and 5).

Findings include:

Review of facility policy, titled "Abuse, Neglect, Exploitation and Misappropriation Prevention Program" last reviewed March 31, 2025, read, in part, "Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Conduct employee background checks and not knowingly employ of otherwise engage any individual who has: been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law."

Review of Employee 4's (Licensed Practical Nurse) personnel file revealed a hire date of March 1, 2025.

Further review of Employee 4's personnel file failed to reveal a criminal background check was conducted at the time of hire.

Review of Employee 5's (Nurse Aide) personnel file revealed a hire date of March 5, 2025.

Further review of Employee 5's personnel file failed to reveal a criminal background check was conducted at the time of hire.

Interview with the Nursing Home Administrator on May 21, 2025, at 10:14 AM, revealed the facility failed to conduct a criminal background check upon hire for the two aforementioned employees, and she would expect them to be conducted at the time of hire.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(e)(1) Management

Plan of Correction - To be completed: 07/09/2025

1)Employee 4 and Employee 5's background checks were run the week of annual survey.
2) Employees files were checked for background checks done by the center at time of hire.

3) Scheduler/HR and Management Team reeducated in regards to F 0607 and the need to do a background for a new hire regardless if they had been prior agency. Scheduler/HR is to have checklist for new hires completed and signed off by Administrator for further verification of this check.

4) Scheduler/HR or designee will audit all new hires for three months. These audits will be reviewed at QAPI.

483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1 ) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).

Observations:

Based on facility policy reviews, clinical record review, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of transfer, or the facility bed-hold policy at the time of transfer, for one of three residents reviewed for hospitalizations (Resident 3).

Findings Include:

Review of facility policy, titled "Facility Bed-Hold and Return to Facility Policy and Procedure" last reviewed March 31, 2025, read, in part, "Before a resident is transferred to the hospital, the facility must provide written information to the resident or the resident representative regarding the facility's bed hold and return policy."

Review of facility, titled "Transfer or Discharge Documentation" last reviewed March 31, 2025, read, in part, "When a resident is transferred or discharged from the facility, the following information will be documented in the medical record: that an appropriate notice was provided to the resident and/or legal representative."

Review of Resident 3's clinical record revealed diagnoses that included heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), anxiety disorder (a persistent feeling of worry, nervousness, or unease), and chronic kidney disease (a condition that results in gradual loss of kidney function).

Review of Resident 3's clinical record revealed she was transferred out of the facility and admitted to the hospital on November 20, 2024, and April 11, 2025.

Further review of Resident 3's clinical record failed to reveal notation that bed hold notices or transfer notices were provided to the Resident or the Resident Representative at either hospitalization.

Interview with the Nursing Home Administrator on May 21, 2025, at 10:29 AM, revealed that it was the responsibility of Employee 3 (Nursing Home Administrator in training) to send bed hold and transfer notices at those times, but that there was misunderstanding, and he was not sending them.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 07/09/2025

1) The facility cannot retroactively correct the bed hold notices that were not given for Resident 3.

2) Checked resident transfers for the 2 weeks for the completion of the bed hold notice for baseline.

3) Reeducated management team on the bed hold process and educated administrative support on the bed hold process and F0628. Administrative support will be the staff responsible for doing this process going forward.

4) Business Office Manager or designee will audit each transfer to the hospital for 60 days to ensure completion of the bed hold notices by the administrative team. This audit will be reviewed at QAPI.

483.25(a)(1)(2) REQUIREMENT Treatment/Devices to Maintain Hearing/Vision:

§483.25(a) Vision and hearing
To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident-

§483.25(a)(1) In making appointments, and

§483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Observations:

Based on record review, observations, and staff interview, it was determined that the facility failed to receive proper treatment and assistive devices to maintain vision and hearing abilities for one of 21 residents reviewed (Resident 36).

Findings Include:

Review of Resident 36's clinical record revealed diagnoses of Dementia (a decline in mental ability, such as memory, thinking, and reasoning, that is severe enough to interfere with daily life) and chronic kidney disease (a progressive condition where the kidneys gradually lose their ability to filter waste and excess fluid from the blood).

Observations of Resident 36 on May 19, 2025, at 1:09 PM; May 20, 2025, at 1:01 PM; and May 21, 2025, at 12:01 PM, revealed Resident 36 lying in bed not wearing hearing aids.

Review of Resident 36's care plan failed to reveal any care plan regarding hearing aids.

Review of Resident 36's current physician orders revealed physician orders to apply Resident 36's hearing aids every morning and remove them every evening, with an order start date of April 14, 2025.

Interview with the Director of Nursing on May 22, 2025, at 10:30 AM, revealed that Resident 36 did not have hearing aids when he arrived from the hospital. Resident 36's family brought his hearing aids in for him on April 14, 2025, the nurse on duty got an order to apply and remove them daily, and she would expect them to be applied daily.

28 Pa code 211.12(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/09/2025

1) Resident 36 hearing aide was immediately applied.
Resident 36 care plan was updated to include the application of the hearing aide.

2) Residents reviewed for use and care plan of hearing aides.

3) Nursing professionals reeducated about the need to care plan and monitor the application of hearing aides and F0685. Hearing aide application is now part of the TAR documentation.

4) Director of Nursing or designee will audit the Care Plans Weekly for 3 months for the care planning of hearing aides. An audit will also be done of the TARs and application of the hearing aides 3 times a week for 3 months. These audits will be reviewed at QAPI.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent accidents for one of two residents reviewed for falls (Resident 46).

Findings include:

Review of facility policy, titled "Fall Risk Assessment" last reviewed on March 31, 2025, read, in part, "The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable."

Review of Resident 46's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) and severe protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets).

Observations in Resident 46's room on May 19, 2025, at 10:41 AM; May 20, 2025, at 9:40 AM; and May 22, 2025, at 11:44 AM; revealed Resident 46 was sleeping in her bed, and she had two fall mats stacked overtop of each other on the left side of her bed.

Review of Resident 46's care plan revealed a focus area the Resident 46 is at risk for falls, last revised October 21, 2024, with an intervention for "fall mats on each side of bed" last revised April 3, 2024.

During an interview with the Director of Nursing on May 22, 2025, at 12:01 PM, she revealed she would expect Resident 46 to have her fall mats on each side of her bed as a fall intervention per her care plan.

28 Pa Code 201.18(b)(1) Management
28 Pa Code 211.12(c)(d)(1)(3)(5) Nursing Services

Plan of Correction - To be completed: 07/09/2025

Resident 46 fall mats were immediately put on both sides of the bed as the care plan indicated.

2) Residents care plans reviewed for fall mat interventions to make sure that they are placed the way the care plan indicates.

3) Nursing professionals and CNAs reeducated on F0689 and making sure the fall mat care plans match what is in place for the residents care environment.

4) Director of Nursing or designee will audit the new fall mat care plans one time a week for three months. An audit will also be done of three time a week of 10% of the fall mat care plans to see if the interventions are placed according to the care plan. These audits will be reviewed at QAPI.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to ensure proper monitoring to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for one of three residents reviewed for nutritional status (Resident 46).

Findings include:

Review of facility policy, titled "Weight Assessment and Intervention" last reviewed on March 31, 2025, read, in part, "The nursing staff will measure resident's weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at that point, weights will be measured monthly thereafter. Weights will be recorded in each unit's weight record chart or notebook and in the individual's medical record. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. The physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss."

Review of Resident 46's clinical record revealed diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) and severe protein-calorie malnutrition (an imbalance between the nutrients the body needs to function and the nutrients it gets).

Review of Resident 46's physician orders revealed an order for "Weights: Monthly weights day shift starting on the 4th and ending on the 4th every month," with a start date of January 4, 2025.

Review of Resident 46's clinical record revealed she had a significant weight loss of 8.7% from February 11, 2025, to March 3, 2025.

Further review of Resident 46's clinical record failed to notify the physician of the significant weight loss.

Interview with Employee 2 (Registered Dietitian) on May 21, 2025, at 12:35 PM, revealed she was notifying the doctor of significant weight losses by paper communication at the time of Resident 46's significant weight loss; however, she recently changed the process to email correspondence, because she was not getting a response from the physician with the paper communications. She further revealed she was unable to produce a physician notification for Resident 46's significant weight loss.

Review of Resident 46's weight measures revealed she failed to have a reweigh measure to confirm her significant weight loss in March 2025, and her clinical record failed to reveal monthly weight measures were obtained during the months of April 2025 and May 2025, per her physician order.

Interview with the Director of Nursing on May 21, 2025, at 2:08 PM, revealed she reviewed Resident 46's April 2025 and May 2025 Treatment Administration Records (documentation for treatments/medication administered or monitored), and they were blank for her weight order, indicating they were not obtained or entered into Resident 46's medical record. She further revealed her expectation that the physician would be notified of significant weight changes, and that weights should be obtained and entered into the clinical record per physician order and facility policy.

28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services

Plan of Correction - To be completed: 07/09/2025

1)Resident 46 was weighed on May 20, 2025. Resident had no significant weight fluctuations

2)Residents checked for weight s have been done according to facility policy.

3) Nursing staff, nursing administration and dietitian reeducated about F0692 and facility policy.

4) Dietitian or designee will audit 10% of weights monthly for three months. These audits will be reviewed at QAPI.

483.35(i)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.35(i) Nurse Staffing Information.
§483.35(i)(1) Data requirements. The facility must post the following information on a daily basis:

(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(i)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (i)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents, staff, and visitors.

§483.35(i)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(i)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Observations:

Based on observations and staff interview, it was determined that the facility failed to post daily current staffing, including the facility name, date, census, and total hours of nursing staff directly responsible for resident care per shift for the following dates: May 19, 20, and 21, 2025.

Findings include:

During entrance to the facility on May 19, 2025, at 9:06 AM, the posted staffing was reviewed and observed to be dated May 16, 2025.

Observation on May 21, 2025, at 1:13 PM, the posted staffing was reviewed and observed to be dated May 19, 2025.

During an interview with the Director of Nursing on May 21, 2025, at 2:06 PM, she confirmed that the Employee 1 (Nursing Scheduler) who is assigned to post the daily staffing didn't post it on the aforementioned dates, and she would expect daily staffing to be posted per the federal regulation.

28 Pa. Code 201.14(a) Responsibility of licensee

Plan of Correction - To be completed: 07/09/2025

1) Posted Staffing was immediately put up after incorrect day was noted.

2) Staffing posting reviewed for 2 weeks following survey.

3) Scheduler/HR, receptionist, and Nursing administration reeducated about F0372 and need to post the daily staffing and adjust if there are changes to what was posted.

4) Scheduler/HR will audit the posted staffing daily during the weekdays for 1 month. This audit will be reviewed at QAPI

§ 201.14(a) LICENSURE Responsibility of licensee.:

(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on staff interview, it was determined that the facility failed to ensure infection control committee meetings were held and include the required members (Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, a community member, laboratory personnel, pharmacy staff).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the Medical Care Availability and Reduction of Error (Mcare) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include...a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members includes Medical Staff, Administration, Nursing Staff, Patient Safety Officer, Physical Plant Personnel, a community member, laboratory personnel, pharmacy staff, and infection control team members.

An interview with the Director of Nursing on May 22, 2025, at 11:30 AM, revealed that the facility did not have infection control meetings, and she is also the infection Preventionist and is the only person on the infection control committee.

The facility was unable to provide evidence that they had an infection control meeting in the past 12 months.

Plan of Correction - To be completed: 07/09/2025

1) The facility cannot retroactively correct the missed Infection Control Meetings.

2) Infection Control Meetings set on calendar for first quarterly post survey.

3) Nursing Administration reeducated about P1020 and the need to have the Infection Control Meeting.

4) Director of Nursing or designee will audit to make sure Infection Control happens quarterly for one year. These audits will be reviewed at QAPI.

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