Pennsylvania Department of Health
BIRCHWOOD REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

BIRCHWOOD REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are 129 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


BIRCHWOOD REHABILITATION & HEALTHCARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, Abbreviated Complaint Survey, Civil Rights, and State Revisit Survey completed on April 4, 2025, it was determined that Birchwood Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B Requirements for Long Term Care Facilities, however remained out of compliance with 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(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Plan of Correction - To be completed: 05/20/2025

1) Resident 56's oxygen tubing was dated.
Resident 68 and 6's concentrator filter was cleaned.

2) To identify other potential areas of concern, Mobile Respiratory Therapist/ designee quality reviewed residents on respiratory therapy oxygen tubing and concentrator filters. Negative findings addressed.

3) To prevent this from recurring, Respiratory Therapist/ designee re-educated nursing staff on the facilities Oxygen Administration Policy and Maintenance of Oxygen concentrators and equipment.

4) To monitor and maintain compliance, DON/designee to quality monitor oxygen tubing and concentrator filter maintenance 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

483.20(f)(1)-(4) REQUIREMENT Encoding/Transmitting Resident Assessments:

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.

§483.20(f) Automated data processing requirement-
§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility:
(i) Admission assessment.
(ii) Annual assessment updates.
(iii) Significant change in status assessments.
(iv) Quarterly review assessments.
(v) A subset of items upon a resident's transfer, reentry, discharge, and death.
(vi) Background (face-sheet) information, if there is no admission assessment.

§483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State.

§483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following:
(i)Admission assessment.
(ii) Annual assessment.
(iii) Significant change in status assessment.
(iv) Significant correction of prior full assessment.
(v) Significant correction of prior quarterly assessment.
(vi) Quarterly review.
(vii) A subset of items upon a resident's transfer, reentry, discharge, and death.
(viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment.

§483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.

Observations:

Based on a review of the Resident Assessment Instrument (RAI) Manual, clinical record review, and staff interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were submitted to the Centers for Medicare & Medicaid Services (CMS) Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) system within the required 14-day timeframe for 2 of 23 residents reviewed (Residents 41 and 45).

Findings include:

According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, version dated October 2019, federally mandated MDS assessments (mandated assessments of a resident's abilities and care needs) must be submitted within 14 calendar days after the MDS Completion Date (Section Z0500B + 14 days). Additionally, discharge tracking records must be completed and transmitted within 14 calendar days following the Event Date (Section A2000 + 14 days).

A review of Resident 41's clinical record revealed a quarterly MDS assessment with an Assessment Reference Date (ARD) of January 2, 2024. This MDS was submitted with identified errors in Section A (Identification Information) and Section C (Cognitive Patterns). The MDS assessment was not corrected and resubmitted to the QIES ASAP system within 14 days of the MDS Completion Date, as required.

A review of Resident 45's clinical record revealed that she was admitted to the facility on May 9, 2024, and discharged from the facility on March 7, 2025.

A review of Resident 45's clinical record revealed the resident was admitted to the facility on May 9, 2024, and discharged on March 7, 2025. A Discharge - Return Not Anticipated MDS assessment was scheduled for March 7, 2025. However, this MDS assessment was in progress and had not been completed or submitted within 14 days of the MDS Completion Date (Section Z0500B + 14 days). The MDS remained unsubmitted until it was identified and completed during the on-site survey conducted April 1-4, 2025.

During an interview conducted on April 3, 2025, at 10:00 AM, the facility's Registered Nurse Assessment Coordinator (RNAC) confirmed that the MDS assessments for Residents 41 and 45 were not submitted to the QIES ASAP system within the required 14-day timeframe.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(3) Management

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

Plan of Correction - To be completed: 05/20/2025

1) Resident 41 and 45 MDS were completed.

2) To identify other potential areas of concern, MDS coordinator quality monitored Quarterly and Discharge MDS. Negative findings addressed.

3) To prevent this from recurring, the Regional MDS Coordinator re-educated facility MDS Coordinator on the completion and timely submission of MDS assessments to the QIES ASAP system.

4) To monitor and maintain compliance, the DON/ designee to quality monitor open MDS due dates to ensure the MDS is completed and submitted within the required timeframe 5x weekly x 4 then 1x weekly x 4. Findings will be forwarded to QA Committee for review and recommendations.

483.20(g) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

Observations:

Based on a review of clinical records and staff interview, it was determined the facility failed to ensure the Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) accurately reflected the status of one out of 23 residents sampled (Resident 49).

Findings included:

A review of Resident 49's clinical record revealed the resident was admitted to the facility on August 2, 2023, with diagnoses that included end stage kidney disease (is a condition where the kidney reaches advanced state of loss of function that causes changes in urination, fatigue, swelling of feet, high blood pressure, and loss of appetite) and required hemodialysis (a machine filters wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work adequately and used to treat advanced kidney failure) three times per week.

A review of Resident 49's quarterly review MDS Assessment dated February 2, 2025, revealed in Section O - O0011.0 Special Treatments, Procedures, and Programs J1. Dialysis was coded "No" and indicated that the resident was not receiving dialysis treatments. However, a review of the resident's clinical record revealed that she received dialysis treatments three times per week to manage kidney disease.

Interview with the Nursing Home Administrator on April 3, 2025, at 1:20 PM, revealed that Resident 49 attended dialysis three times per week and confirmed the facility failed to code the February 2, 2025, quarterly MDS to reflect dialysis as a special treatment.

28 Pa. Code 211.5 (f)(iv) Medical records.

28 Pa. Code 211.12(d)(2)(3) Nursing services.

Plan of Correction - To be completed: 05/20/2025

1) Resident 49's MDS Section "O" was corrected.

2) To identify other potential areas of concern, MDS Coordinator/ designee quality monitored residents who receive dialysis to ensure accuracy of MDS. Negative findings addressed.

3) The prevent this from recurring, the Regional MDS Coordinator re-educated the facility MDS Coordinator on accuracy of the MDS.

4) To monitor and maintain compliance, the DON/ designee to quality monitor MDS for accuracy 5x weekly x 4 then 1x weekly x 4. Findings will be forwarded to QA Committee for review and recommendations.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on clinical record review and staff interview, it was determined the facility failed to develop and implement a baseline care plan that included the minimum healthcare information necessary to address the resident's immediate care and safety needs upon admission for one of 23 residents reviewed (Resident 318).

Findings:

A review of Resident 318's clinical record revealed the resident was admitted to the facility on March 28,2025, with diagnoses including osteomyelitis (an infection in a bone) and diabetes mellitus (a metabolic disorder in which the body has elevated blood sugar levels for prolonged periods of time).

A review of a social services progress note dated March 30, 2025, at 5:15 PM, indicated that Resident 318 did not speak English very well.

Further review of Resident 318's baseline care plan revealed it failed to identify English as a second language as part of the resident's communication needs. Additionally, the baseline care plan failed to include measurable goals, objectives, or interventions to address the resident's communication barrier or outline strategies to ensure staff could effectively communicate with the resident to meet his immediate care and safety needs.

During an interview on April 3, 2025, at approximately 2:00 PM, the Director of Nursing confirmed that Resident 318's baseline care plan did not include the resident's communication needs or any interventions to address the language barrier. The Director of Nursing acknowledged the baseline care plan failed to reflect the minimum necessary information to ensure staff were provided with clear instructions to meet the resident's immediate care needs upon admission.

28 Pa Code 211.12 (d)(1)(2)(3)(5) Nursing Services.

Plan of Correction - To be completed: 05/20/2025

1) Resident 318 care plan was updated.

2) To identify other potential areas of concern, Social Service Director quality monitored newly admitted resident baseline care plans as of 4/1/2025 to ensure baseline care plans to ensure person center interventions are in place. Negative findings addressed.

3) To prevent this from recurring, the DON/designee re-educated the Social Service Director on updating care plans after identifying necessary information to meet resident needs.

4) To monitor and maintain compliance, the Social Service Director to quality monitor newly admitted resident baseline care plans for person centered interventions 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on select facility policy, a review of clinical records and resident and staff interviews it was determined that the facility failed to provide nursing services consistent with professional standards of quality by failing to ensure that licensed nurses timely administered a resident's medications for one resident of 23 reviewed (Resident 56).

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 was to 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 judgement 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.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care including Medication Records.

A review of facility policy titled: "Administering Medications" last reviewed by the facility on March 3, 2025, indicated that medications are administered within one hour of their prescribed times, unless otherwise specified.

Review of Resident 56's clinical record revealed the resident was admitted to the facility on June 10, 2023, with diagnoses to include pulmonary hypertension (a type of high blood pressure that affects arteries in the lungs and in the right side of the heart), heart failure (chronic, progressive condition in which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen), and osteoarthritis (a degenerative joint disease that occurs when tissues that cushion the ends of bones within the joints break down).

During an interview with Resident 56 on April 1, 2025, at 11:00 AM she expressed frustration regarding delays in the administration of her medications. She reported that her physician prescribed morphine (an opioid pain-relieving medication used to treat moderate to severe pain) was often given late. As a result, the delayed administration caused an increase in her pain and led to extreme discomfort.

A review of Resident 56's Medication Administration Record for March 2025, revealed that the resident was prescribed and scheduled to receive the following medications:
Gas-X Extra Strength tablet by mouth at 9:00 AM
Artificial tears solution, two drops in both eyes at 9:00 AM
Zyprexa 5 MG tablet (atypical antipsychotic) by mouth at 9:00 AM
Detrol 2 MG tablet (antispasmodic)by mouth at 9:00 AM
Acidophilus capsule (probiotic)by mouth at 9:00 AM
Metoprolol 50 MG (antihypertensive) tablet my mouth at 9:00 AM
Colace 100 MG capsules (stool softener) by mouth at 9:00 AM
MS Contin (morphine sulfate narcotic pain medication) 60 MG tablet by mouth at 9:00 AM
Acetaminophen 500 MG tablet by mouth at 9:00 AM

Review of the facility's Medication Administration Audit Report for March 21, 2025, through March 24, 2025, revealed the following:

On March 23, 2025, Resident 56's medications scheduled for 9:00 AM were not administered until 10:35 AM, 1 hour and 35 minutes after the scheduled time.

On March 24, 2025, Resident 56's medications scheduled for 9:00 AM were not administered until 10:58 AM, 1 hour and 58 minutes after the scheduled time

Interview with the Nursing Home Administrator on April 3, 2025, at approximately 1:30 PM confirmed medications should be administered timely in accordance with physician orders and professional standards of practice.

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

Plan of Correction - To be completed: 05/20/2025

1) The facility cannot retroactively correct past medication administration.

2) To identify other areas of concern, the DON/designee quality monitored current resident MARS to ensure medications are being passed timely. Negative findings addressed.

3) To prevent this from recurring, DON/designee re-educated licensed nursing on the facility's Medication Administration Policy.

4) To monitor and maintain compliance, DON/ designee to quality monitor timely medication administration 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:

§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

Observations:

Based on clinical record review, facility policy review, and staff interviews, it was determined the facility failed to ensure a timely and thorough assessment of pressure ulcers/injuries upon admission for one of 23 sampled residents (Resident 39).

Findings included:

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 a facility policy entitled "Pressure Injuries Overview" last reviewed by the facility on March 3, 2025, indicated that a pressure ulcer/injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually cover a bony prominence or related to a medical or other device. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. Pressure ulcers/injuries occur as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by skin temperature, moisture, nutrition, perfusion, co-morbidities, and conditions of the soft tissue.

A review of Resident 39's clinical record revealed the resident was admitted to the facility on January 30, 2025, with diagnoses that included malignant neoplasm of the bladder (another term for bladder cancer, is a common type of cancer that begins in the cells of the bladder), malnutrition (condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs), colostomy (surgical procedure that creates an opening in the abdominal wall to drain stool from the colon and can be temporary or permanent, depending on the condition of the bowel), abscess of the vulva (collection of pus that forms in the tissues of the vulva, which is the outer part of the female genitalia and is a condition that can be caused by a bacterial infection that enters the skin through a cut or a hair follicle), and cutaneous abscess of the perineum (painful, pus-filled bump near the anus or rectum. It occurs when an anal gland gets clogged and infected).

A review of the resident's admission/readmission evaluation - v2 completed by Employee 6, a Registered Nurse (RN), dated January 30, 2025, at 5:09 PM, revealed the resident was observed with skin impairments that included pressure and other skin impairments that included an abscess of the perineum and vulva and excoriation (scratching or rubbing the skin, leading to abrasions or erosions) of the colostomy peristomal (area of skin around the colostomy).

Employee 6 completed an admission body audit form dated January 30, 2025, that revealed that Resident 39 had a stage III pressure ulcer ( pressure injury characterized by full-thickness skin loss where the ulcer has broken through the top two layers of skin and into the fatty tissue below, resembling a hole or crater with potential for a foul odor) to the sacrum (triangular-shaped bone that connects the spine with the hip and supports the pelvic organs).

However, there was no documented evidence that Employee 6 completed a thorough wound assessment of the pressure ulcer/injury, as required, to include specific measurements (length, width, depth, and surface area) or a detailed description of the wound characteristics.

A review of a skin and wound note completed by the facility's contracted wound care specialist CRNP (Certified Registered Nurse Practitioner) dated February 3, 2025, at 9:01 PM (four days after admission), identified wound number two (#2) as a stage IV pressure ulcer/injury full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead tissue) may be present on some parts of the wound bed. (to the right gluteal fold that was present on admission. Current size at 5.0 centimeters (cm) in length by 3.0 in width cm by 0.5 cm in depth and calculated area was 15 square centimeters (sq cm) with 100% granulation (is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process) present at the wound base and moderate amount of serosanguineous exudate (is a type of wound drainage secreted by an open wound in response to tissue damage).

The facility was unable to provide documentation to demonstrate that a timely and thorough assessment of Resident 39's pressure ulcer/injury was completed by an RN upon admission to include measurements and a detailed wound description.

During an interview with the Director of Nursing (DON) on April 3, 2025, at 1:30 PM, the DON stated that it is the expectation that upon admission, the RN is to complete a thorough wound assessment that includes measurements and wound description, which should be documented in the resident's clinical record.

An interview with the Director of Nursing (DON) on April 3, 2025, at 1:30 PM, stated that it is the expectation that upon admission to the facility the RN is to complete a thorough wound assessment that includes measurements and wound description, which should be documented in the resident's clinical record.

During a follow-up interview with the DON on April 4, 2025, at 10:15 AM, the DON confirmed that the facility failed to ensure a timely and thorough wound assessment of Resident 39's pressure ulcer/injury was completed upon admission, including measurements and description of the wound by an RN.

8 Pa. Code 211.10(d) Resident care policies.

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

Plan of Correction - To be completed: 05/20/2025

1) Wound evaluation completed on Resident 39

2) To identify other areas of concern, DON/designee quality monitored new admissions from 4/1/25 to current to ensure wound evaluations are completed within 24 hours of admission.

3) To prevent this from recurring, DON/designee re-educated licensed nursing staff on completion of wound evaluations.

4) To monitor and maintain compliance, DON/designee to quality monitor new admissions 5x weekly x 4 weeks then 1x weekly x 4 weeks to ensure wound evaluations are completed timely. Findings will be forwarded to QA Committee for review and recommendations.

483.25(g)(4)(5) REQUIREMENT Tube Feeding Mgmt/Restore Eating Skills:

§483.25(g)(4)-(5) Enteral Nutrition
(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)(4) A resident who has been able to eat enough alone or with assistance is not fed by enteral methods unless the resident's clinical condition demonstrates that enteral feeding was clinically indicated and consented to by the resident; and

§483.25(g)(5) A resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers.

Observations:

Based on observations, select policy review, a review of clinical records, and staff interview it was determined 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 23 residents sampled (Resident 58).

Findings include:

Review of a facility policy titled "Enteral Feedings - Safety Precautions" last reviewed by the facility on March 3, 2025, indicated that all personnel responsible for preparing , storing and administering enteral nutrition (tube inserted through the abdomen directly into the stomach, used to deliver nutrition, fluids, and medications when a person cannot eat or drink safely or consume enough calories orally) formulas will be trained, qualified and competent and that the facility will remain current in and follow accepted best practices in enteral nutrition. Further it indicated that to prevent aspiration (occurs when food or liquid enters the lungs instead of the stomach, which can lead to serious health problems) elevate the head of the bed at least 30 degrees during tube feeding and at least 1 hour after feeding.

Review of Resident 58's clinical record revealed the resident was admitted to the facility on July 12, 2021, with diagnoses to include dysphagia (difficulty swallowing) and functional quadriplegia (complete immobility due to severe disability or facility, stemming from a medical condition without brain or spinal cord injury).

Resident 58 required a PEG tube (Percutaneous endoscopic gastrostomy- an endoscopic medical procedure in which a 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 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 the Resident 58's plan of care for PEG tube dated September 4, 2023, revealed an intervention to elevate the head of the bed 30 degrees during feeding and medication administration. Review of the plan of care for activities of daily living revealed an intervention to keep the head of bed elevated at all times.

A review of resident 58's current physician's order dated April 2, 2024, revealed an order to elevate the head of the bed 30 degrees or higher during and 1 hour post feeding. Another current physician's order dated May 9, 2024, revealed on order for enteral feed (a method of providing nutrition directly into the GI tract through a tube), elevate the head of the bed at least 30 degrees during feeding, any medication administration, and for 30 minutes after feeding. Another current physician's order dated August 28, 2024, revealed an order to elevate the head of the bed at least 30 degrees during feeding and any mediation administration.

An observation on April 1, 2025, at 12:15 PM revealed Resident 58's enteral tube feeding was actively infusing. The resident was awake and lying in bed. The head of the bed was not elevated, and the resident was lying flat on her back on the bed while the enteral tube feed was infusing.

Interview with Employee 1 (licensed practical nurse) on April 1, 2025, at 12:20 PM confirmed that Resident 58's tube feeding was actively infusing, and the head of the bed was not elevated.

Interview with the Director of Nursing on April 4, 2025, at approximately 2:15 PM, confirmed the facility failed to provide care and services designed to prevent potential complications associated with tube feedings.

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

Plan of Correction - To be completed: 05/20/2025

1) Resident 58's care plan and order were updated.

2) To identify other potential areas of concern, DON/ designee quality monitored residents with tube feeds care plans and orders. No issues noted.

3) To prevent this from recurring, DON/designee re-educated nursing staff on facility's Eternal Feeding Safety Precautions Policy.

4) To monitor and maintain compliance, DON/ designee to quality monitor resident positioning while receiving tube feeding 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

483.25(k) REQUIREMENT Pain Management:

§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Plan of Correction - To be completed: 05/20/2025

1) Resident 114 discharged from facility

2) To identify other potential areas of concern, DON/designee quality monitored current residents as of 4/1/25 with opioid PRN pain medications for non-pharmacological interventions.

3) To prevent this from recurring, DON/designee re-educated licensed nursing staff on PRN opioid pain medication administration and non-pharmacological intervention documentation.

4) To monitor and maintain compliance, DON/designee to quality monitor opioid PRN medication for appropriate use of non-pharmacological interventions 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

483.40(a)(1)(2) REQUIREMENT Sufficient/Competent Staff-Behav Health Needs:

§483.40(a) The facility must have sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with §483.71. These competencies and skills sets include, but are not limited to, knowledge of and appropriate training and supervision for:

§483.40(a)(1) Caring for residents with mental and psychosocial disorders, as well as residents with a history of trauma and/or post-traumatic stress disorder, that have been identified in the facility assessment conducted pursuant to §483.71, and

§483.40(a)(2) Implementing non-pharmacological interventions.

Observations:

Based on observations, a review of clinical records, resident and staff interviews, it was determined the facility failed to provide sufficient staff who provide direct services to residents with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as evidenced by one resident out of 21 sampled (Resident 97).

Findings include:

Review of the facility policy titled "Behavioral Assessment, Intervention, and Monitoring" last reviewed March 3, 2025, indicated the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Furthermore, if the resident is being treated for altered behavior or mood, the interdisciplinary team will seek and document any improvements or worsening in the individual's behavior, mood, and function.

An interview with Resident 97 on April 2, 2025 at 8:30 AM revealed the resident was experiencing increased anxiety over the past several weeks. The resident reported the nurse practitioner would not increase her anti-anxiety medication since the nursing documentation did not reflect any increase in symptoms.

Review of Resident 97's clinical record revealed that the resident was admitted to the facility on July 2, 2024, with diagnoses to include bipolar disorder (a condition characterized by mood swings), generalized anxiety disorder, and depression.

A quarterly Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) for Resident 97 dated February 22, 2025, indicated the resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 13-15 indicates cognition is intact).

Review of Resident 97's care plan initially dated September 17, 2024, and revised on December 9, 2024, revealed the resident has an impaired psychiatric/mood status related to anxiety, bipolar disorder, and depression.

Clinical record revealed on November 29, 2024, the physician, ordered Clonazepam 0.5 MG (anti anxiety medication) 1 tablet by mouth two times a day related to generalized anxiety disorder and antianxiety behavior tracking (documenting number of signs and symptoms of anxiety each shift based on individual observation of patient and discussion with other care team members).

Review of the Medication Administration Record (MAR) dated from March 1, 2025, through March 31, 2025 indicated the following anxiety behavior chart codes: NB (no behaviors noted), OBI (observed individual), OBA (group observed all), and 7 (sleeping). The March MAR revealed only 11 incidences whereby anxiety behavior codes were documented for the corresponding shift. There were an additional 5 shifts (March 24 evening, March 26 -27 nights, March 29 nights and March 31 days) whereby behavioral status was addressed in the progress note as opposed to the MAR. The majority of shifts (77) for the month did not document anxiety behavior tracking in the MAR nor progress notes.

A psychiatry note dated March 25, 2025 at 6:30 AM indicated that Resident 97 reported that anxiety continues and now it is affecting her sleep at night as well as some depression overall, staff and progress notes do not note any anxiety but resident does ambulate in a wheelchair throughout the facility and reports she is constantly worried about everything. Recommendations included continuing to monitor resident and document any changes in mood or behaviors in the electronic health record to assist with medication management.

A review of the Medication Administration Record dated from April 1, 2025 through April 4, 2025 revealed no shift documentation of behaviors on the MAR but 3 progress notes that addressed anxiety symptoms.

An interview with the Director of Nursing (DON) on April 4, 2025, at approximately 8:45 AM, confirmed anxiety behaviors were not documented per the physician orders. The facility failed to provide documented evidence the facility employed sufficient staff with the necessary competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents.

28 Pa. Code 211.12 (d)(3)(4)(5) Nursing services

28 Pa. Code 201.18 (e)(1)(3) Management

Plan of Correction - To be completed: 05/20/2025

1) Resident 97 seen by psychiatric nurse practitioner

2) To identify other potential areas of concern, DON/designee quality monitored behavioral tracking for current residents as of 4/1/25 receiving anti-anxiety medications. Negative findings addressed.

3) To prevent this from recurring, the DON/designee re-educated licensed nursing staff on behavior documentation within the MAR.

To prevent this from recurring, DON/designee updated behavior tracking orders to reflect person centered behaviors.

4) The monitor and maintain compliance, Social Service Director/designee to quality monitor behavior documentation for residents with anti-anxiety medications 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use:

§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Observations:

Based on record review and staff interview, the facility failed to ensure that a PRN (as-needed) psychotropic medication was limited to 14 days without a documented physician rationale for extension and failed to document the use of non-pharmacological interventions prior to administering a PRN antianxiety medication, for Resident #39.

Findings include:

A review of Resident 39's clinical record revealed that the resident was admitted to the facility on January 30, 2025, with diagnoses that included malignant neoplasm of the bladder (another term for bladder cancer, is a common type of cancer that begins in the cells of the bladder), malnutrition (is the condition that develops when the body is deprived of vitamins, minerals and other nutrients it needs), and anxiety disorder (a mental health conditions that cause excessive fear and worry in response to situations).

A review of Resident 39's physician orders revealed an order dated February 6, 2025, at 11:50 AM, for Ativan (lorazepam a benzodiazepine that work by enhancing the activity of certain neurotransmitters in the brain and used to treat anxiety disorders) oral tablet 0.5 MG, give 0.5 mg by mouth every 8 hours as needed (PRN) for anxiety.

Review of Resident 39's electronic medication administration record (eMAR technology that automates data entry for the administration of medication to patients in healthcare settings and the digital records contain details about the prescribed medication regimen, dosage, timing, and administering staff) dated February 6, 2025, through March 26, 2025, revealed that Lorazepam was administered prior to licensed nursing staff attempting and documenting that non-pharmacological interventions were attempted prior to administering the antianxiety medication.

The following dates and times PRN Ativan was administered with no documentation found in the clinical record indicating that non-pharmacological interventions (such as redirection, reassurance, or other calming techniques) were attempted prior to each administration of the PRN Ativan during this period.

February 9, 2025, at 11:55 PM
February 10, 2025, at 12:07 AM
February 12, 2025, at 3:55 PM
February 13, 2025, at 2:21 PM
February 14, 2025, at 7:32 PM
February 15, 2025, at 11:56 AM
February 15, 2025, at 8:08 PM
February 16, 2025, at 11:48 AM
February 16, 2025, at 8:13 PM
February 17, 2025, at 12:26 AM
February 18, 2025, at 9:38 PM
February 19, 2025, at 2:56 PM
February 20, 2025, at 8:48 AM
February 20, 2025, at 5:40 PM
February 21, 2025, at 2:07 PM
February 22, 2025, at 7:19 AM
February 22, 2025, at 5:37 PM
February 23, 2025, at 11:00 AM
February 23, 2025, at 7:48 PM
February 24, 2025, at 1:00 PM
February 25, 2025, at 2:22 PM
February 25, 2025, at 11:00 PM
February 27, 2025, at 8:26 AM
February 27, 2025, at 5:35 PM
February 28, 2025, at 6:56 PM
March 1, 2025, at 1:58 PM
March 2, 2025, at 1:23 PM
March 3, 2025, at 1:03 PM
March 4, 2025, at 8:57 AM
March 5, 2025, at 3:54 AM
March 5, 2025, at 12:33 PM
March 5, 2025, at 8:34 PM
March 6, 2025, at 8:47 AM
March 6, 2025, at 7:17 PM
March 7, 2025, at 8:07 PM
March 8, 2025, at 1:19 PM
March 8, 2025, at 9:25 PM
March 9, 2025, at 9:51 PM
March 10, 2025, at 5:55 AM
March 11, 2025, at 10:01 AM
March 11, 2025, at 5:07 PM
March 12, 2025, at 7:10 PM
March 13, 2025, at 5:40 AM
March 13, 2025, at 1:59 PM
March 13, 2025, at 10:00 PM
March 15, 2025, at 1:59 PM
March 16, 2025, at 10:48 PM
March 17, 2025, at 4:51 PM
March 18, 2025, at 9:01 AM
March 19, 2025, at 1:06 PM
Mach 19, 2025, at 9:00 PM
March 20, 2025, at 12:29 AM
March 20, 2025, at 9:24 PM
March 21, 2025, at 6:08 PM
March 22, 2025, at 10:29 PM
March 24, 2025, at 1:14 AM
March 24, 2024, at 1:41 PM
March 25, 2025, at 3:49 PM

Record review also showed that the PRN Ativan order dated February 6. 2025 remained active and in use beyond 14 days from its initiation without a documented rationale from the attending physician to justify extending the order
Additionally, the facility failed to provide documented evidence that non-pharmacological interventions were attempted prior to administration of the PRN anxiety medication.

Interview with the Director of Nursing (DON) on April 4, 2025, at 2:00 PM confirmed that Resident 39 had a PRN order for Ativan that remained in effect longer than 14 days without the attending physician documenting a rationale for its continued use. The DON could not provide evidence of documentation of any non-pharmacological interventions attempted prior to administering the PRN Ativan for Resident 39's episodes of anxiety. She stated that it was the facility's expectation to utilize and document non-pharmacological approaches (such as diversion or comfort measures) before giving a PRN antianxiety medication and verified that in this case no such documentation was present in the resident's record. The lack of documented physician justification for extending the PRN psychotropic medication order beyond 14 days, combined with the absence of documented alternative interventions before each PRN dose, did not meet the required standard of practice and regulatory requirements for PRN psychotropic medication use.

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

28 Pa. Code 211.9(a) (1) Pharmacy Services

28 Pa. Code 211.2(3) Medical Director

Plan of Correction - To be completed: 05/20/2025

1) Resident 39 order updated.

2) To identify other potential areas of concern, DON/designee quality monitored current residents as of 4/1/25 on PRN psychotropic medications for non-pharmacological interventions prior to administration medication.
To identify other potential areas of concern, DON/ designee quality monitored current residents as of 4/1/25 on PRN psychotropic medications for 14 day stop dates
To identify other potential areas of concern, DON/ designee quality monitored current residents as of 4/1/25 on PRN psychotropic medications for MD notification and documentation for continued usage of PRN psychotropic medication.
3) To prevent this from recurring, DON/designee re-educated licensed nursing staff on non-pharmacological interventions prior to administering PRN psychotropic medication.

To prevent this from recurring, DON/designee re-educated licensed nursing staff on 14 day stop dates for PRN medication.

To prevent this form recurring, DON/ designee re-educated licensed nursing staff on MDS notification and documentation for continued usage of PRN psychotropic medication.

4) To monitor and maintain compliance, DON/designee to quality monitor residents on PRN psychotropic medications have non-pharmacological interventions 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

To monitor and maintain compliance, DON/designee to quality monitor residents on PRN psychotropic medications have 14 days stop dates 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

To monitor and maintain compliance, DON/designee to quality monitor residents on PRN psychotropic medications have MDS notification and documentation for continued use 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of the facility's Medication Storage and Labeling policy, observations, manufacturer's instructions, and staff interviews, it was determined that the facility failed to ensure medications and biologicals were stored and labeled in accordance with professional standards and manufacturer recommendations. Specifically, the facility failed to ensure that opened multi-dose medication vials were labeled with an open date and failed to ensure that expired intravenous (IV) supplies were not available for resident use on two of two nursing areas (First Floor Nursing Unit and First Floor Medication Room).

Findings include:

Review of the facility Medication Storage and Labeling policy last reviewed March 3, 2025, indicated that medications and biologicals (medications that come from living organisms) are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Multi dose vials which have been opened or accessed (e.g., needle puncture) should be dated and discarded withing 28 days unless the manufacturer specifies a different (longer or shorter) date for that opened vial.

Observation of the medication refrigerator located in the nurse's station on the First Floor Nursing Unit on April 3, 2025, at 9:11 AM, in the presence of Employee 5 LPN (Licensed Practical Nurse), revealed one vial of Acetylcysteine Solution 10% (a solution used via nebulizer to help loosen thick, sticky mucus) that had been opened but was not labeled with an open date.

An interview with Employee 1LPN at the time of the observation confirmed the Acetylcyst Solution 10% stored in the medication refrigerator was opened and not dated.

Review of the manufacturer's storage instructions for Acetylcysteine Solution 10% indicated the solution should be refrigerated after opening and discarded after 96 hours (4 days).

An interview with the Director of Nursing (DON) on April 3, 2025, at approximately 2:00 PM confirmed that the vial of Acetylcysteine Solution 10% stored in the medication refrigerator had been opened and was not dated.

A second observation of the medication room located on the First Floor Nursing Unit on April 3, 2025, at 9:11 AM, in the presence of Employee 5 LPN, revealed the following expired intravenous (IV) supplies available for use:
Two (2) Intravenous Winged Infusion Sets 20 Gauge (a device specialized for venipuncture for either blood draws or intravenous injection) with an expiration date of December 31, 2023; and
One (1) BD Safety IV Catheter Insertion Kit (used for intravenous infusion therapy) with an expiration date of March 31, 2025.

An interview with the Director of Nursing (DON)) on April 3,2025, at approximately 2:00 PM confirmed the intravenous supplies stored in the medication room located on the First floor Nursing unit were expired.

28 Pa. Code 211.9 (a)(1)(k) Pharmacy Services

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

Plan of Correction - To be completed: 05/20/2025

1) The medication was discarded.
Expired IV supply was discarded

2) To identify other areas of potential concern, DON/designee quality monitored current residents as if 4/1/25 medications for open dates. Negative findings addressed.
To identify other areas of potential concern, DON/designee quality monitored IV supplies for expiration dates. No issues noted.

3) To prevent this from recurring, DON/designee re-educated licensed nursing staff on dating medications with date it was opened.

To prevent this from recurring, DON/designee re-educated licensed nursing staff on ensuring IV supplies are within date.

4) To monitor and maintain compliance, DON/designee to quality monitor medications, if opened, are dated and not expired 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

To monitor and maintain compliance, DON/designee to quality monitor IV supplies for expiration dates 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

§ 204.7 LICENSURE Laundry.:

Equipment shall be made available and accessible for residents desiring to do their personal laundry.

Observations:

Based on review of Resident Council meeting minutes and resident and staff interviews, it was determined the facility failed to ensure that laundry equipment was available for residents to do their personal laundry for 6 out of 23 residents reviewed (Residents 75, 93, 45, 13, 97, and 72).

Findings include:

Review of the facility's Resident Council meeting minutes dated January 8, 2025, under the area of "New Business", Residents 75, 93, 45, 13, and 97 asked if they could wash their own laundry at the facility. They were informed that the facility does not have a washer or dryer available for the residents to use. It further indicated the Nursing Home Administrator (NHA) would be notified of their concern.

Review of the Resident Council meeting minutes dated February 6, 2025, under "Old Business" revealed the NHA responded to their concern about residents doing their own laundry. He stated that the "facility does not have an area for residents to independently wash and dry their own clothes."

During a group meeting with five alert and oriented residents (Residents 19, 97, 75, 70, and 72) on April 2, 2025, at 10:00 AM all residents in attendance reported that the NHA told the group the facility does not have a washer and dryer for resident use. Residents 97 and 72 indicated they would prefer to do their own laundry. Resident 97 expressed frustration that her clothes are fading and shrinking due to the facility laundering all her clothes in hot water.

During an interview with NHA on April 2, 2025, at 12:20 PM, the NHA confirmed the facility does not have laundry equipment for residents to do their personal laundry.

Plan of Correction - To be completed: 05/20/2025

1) Facility to cannot retroactively correct not having laundry equipment for residents to do their personal laundry.
2) To identify other potential areas for concern, NHA/ designee held ADHOC Resident council and informed residents of new washer/dryer unit and location.
3) To prevent this from recurring, Regional VP of Operations re-educated NHA on P2780 state regulation.
4) To monitor and maintain compliance, Laundry Supervisor/designee to quality monitor residential style washer/dryer to ensure unit is within working order 5x weekly x 1 week then 1x weekly x 2 months. Findings will be forwarded to QA Committee for review and recommendation.

§ 211.5(f)(i)-(xi) LICENSURE Medical records.:

(f) In addition to the items required under 42 CFR 483.70(i)(5) (relating to administration), a resident ' s medical record shall include at a minimum:
(i) Physicians' orders.
(ii) Observation and progress notes.
(iii) Nurses' notes.
(iv) Medical and nursing history and physical examination reports.
(v) Admission data.
(vi) Hospital diagnoses authentication.
(vii) Report from attending physician or transfer form.
(vii) Diagnostic and therapeutic orders.
(viii) Reports of treatments.
(ix) Clinical findings.
(x) Medication records.
(xi) Discharge summary, including final diagnosis and prognosis or cause of death.

Observations:

Based on a review of closed clinical records and staff interview, it was determined that the facility failed to ensure that a discharge summary, with the physician's final diagnosis and cause of death, was completed for one out of three discharged residents reviewed (Resident 170).

Findings include:

A review of Resident 170's closed clinical record revealed the resident was admitted to the facility on February 1, 2025. The resident expired at the facility on February 21, 2025.

A review of the resident's closed clinical record on April 4, 2025, revealed the resident's record did not contain a physician's discharge summary with the resident's final diagnosis and cause of death.

An interview with the Nursing Home Administrator on April 4, 2025, at approximately 12:20 PM confirmed the facility could not provide documentation a physician discharge summary was completed for Resident 170.

Plan of Correction - To be completed: 05/20/2025

1) Resident 170 discharge summary completed.

2) To identify other areas of potential concern, Medical Records Director/ designee quality monitored closed resident charts going back to 4/1/25. Negative findings addressed.

3) To prevent this from recurring, NHA re-educated Medical Records Director on ensuring discharge summary, with physician final diagnosis and cause of death is completed prior to closing the discharged residents' chart.

4) To monitor and maintain compliance, the Medical Records Director/ designee to quality monitor discharged resident charts prior to closing to ensure a discharge summary, with the physician's final diagnosis and cause of death, is completed prior to closing the chart 5x weekly x 4 weeks then 1x weekly x 4 weeks. Findings will be forwarded to QA Committee for review and recommendations.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 05/20/2025

1. Facility cannot retroactively correct nurse aide staffing ratio.
2. Director of Nursing/Designee will conduct an initial audit of the next two weeks' schedule determine if nurse aide ratio is in compliance.
3. Director of Nursing or Designee will re-educate the scheduler on the proper nurse aide staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. Incentives put in place for staff to pick up shifts, not call out and assist with recruiting efforts.
4. Director of Nursing/Designee will conduct random audits of nurse aide staffing weekly for four weeks, then monthly for two months thereafter to verify proper nurse aide ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

§ 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based on review of nursing time schedules and staff interviews, it was determined that the facility failed to provide a minimum of one licensed practical nurse (LPN) on nine out of 63 shifts reviewed (February 8, 2025, through February 14, 2025, and February 15, 2025, through February 21, 2025, and March 27, 2025, through April 2, 2025).

Findings included:

A review of the facility's weekly staffing records revealed that on the following dates the facility failed to provide a minimum of one LPN per 25 residents during the day shift, a minimum of one LPN per 30 residents during the evening shift, and a minimum of one LPN per 40 residents during the night shift.

February 9, 2025 - 3.17 LPNs worked evening shift versus the required 3.57 for a census of 107.
February 14, 2025 - 3.03 LPNs worked evening shift versus the required 3.80 for a census of 114.
February 14, 2025 - 2.17 LPNs were on the night shift versus the required 2.85 for a census of 114.
February 15, 2025, - 4.32 LPNs worked day shift versus the required 4.56 LPNs for a census of 114.
March 29, 2025 - 4.09 LPNs worked day shift versus the required 4.32 for a census of 108.
March 30, 2025 - 4.30 LPNs worked day shift versus the required 4.36 for a census of 109.
March 30, 2025 - 2.97 LPNs worked the evening shift versus the required 3.63 for a census of 109.
April 1, 2025 - 3.97 LPNs worked day shift versus the required 4.20 for a census of 105.
April 2, 2025 - 4.00 LPNs worked day shift versus the required 4.20 for a census of 105.

No additional excess higher-level staff were available to compensate this deficiency.

An interview with the Nursing Home Administrator (NHA) on April 4, 2025, at 2:00 PM, confirmed that the facility did not meet the state minimum nursing ratios for LPNs required.

Plan of Correction - To be completed: 05/20/2025

1. Facility cannot retroactively correct LPN staffing ratio.
2. Director of Nursing/Designee will conduct an initial audit of the next two weeks schedule to determine if LPN ratio is in compliance.
3. Director of Nursing/Designee will re-educate the scheduler on the proper LPN staffing ratios. The facility will hold labor meetings Monday-Friday to verify ratios are made. Incentives put in place for staff to pick up shifts, not call out and assist with recruiting efforts.
4. Director of Nursing/Designee will conduct random audits of LPN staffing weekly for four weeks, then monthly for two months thereafter to verify proper LPN ratios. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 05/20/2025

1. Facility cannot retroactively correct the overall PPD.
2. Director of Nursing/Designee will conduct an initial audit of the next two weeks schedule to determine if the overall PPD is in compliance.
3. Director of Nursing/Designee will re-educate the scheduler on the proper staffing PPD. The facility will hold labor meetings Monday-Friday to verify PPD is are met. Incentives put in place for staff to pick up shifts, not call out and assist with recruiting efforts.
4. Director of Nursing/Designee will conduct random audits of overall PPD then monthly for two months thereafter to verify proper PPD. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.

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