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 122 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, State Licensure, Civil Rights Compliance, and Abbreviated Complaint Survey completed on June 7, 2024, 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 and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

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

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(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 a review of clinical records, observations and staff and resident interviews it was determined that the facility failed to provide planned care and services, consistent with professional standards of practice to treat pressure sores and prevent worsening for one resident out of 19 sampled (Resident 32).

Findings included:

A review of Resident 32's clinical record revealed that the resident was initially admitted to the facility on June 11, 2020, with diagnoses to have included a cerebral infarction [occurs when the blood supply to part of the brain is blocked or reduced, which prevents brain tissue from getting oxygen and nutrients that result in brain cells dying], vascular dementia [is a general term describing problems with reasoning, planning, judgment, memory and other thought processes caused by brain damage from impaired blood flow to your brain], congestive heart failure [(CHF) is a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply that results in blood and fluids building-up in the lungs and legs over time], and chronic pressure ulcer to the right outer foot.

A review of Resident 32's plan of care for skin impairment initiated on July 24, 2023, indicated that he was at risk for impaired skin integrity related hemiplegia with right sided weakness, incontinence, decreased mobility, use of a molded ankle-foot orthosis [(MAFO) is an orthotic device used to control foot and ankle alignment and compensate for muscle weakness that should be worn based on a wearing schedule to prevent skin irritation and breakdown] splint to right lower extremity. According to the resident's care plan on September 16, 2024, the resident had a calloused blister to his right foot. Planned interventions included skin checks every shift to the right foot related to use of a MAFO splint, administer medication(s) and apply treatment(s) as per physician/nurse practitioner/physician assistant, skin checks every seven days, and if resident refuses interventions, encourage compliance to minimize risk for skin impairments.

A review of a podiatry consultation in Resident 32's clinical record dated February 12, 2024, revealed that the resident was seen due to chronic pain in his right foot and indicated that the pain was related to a pressure ulcer. The podiatrist's recommendations included to cleanse the area with saline and apply Betadine and cover with a dry sterile dressing BID (twice per day) and to hold the use/wearing of the resident's MAFO for two weeks.

A review of the resident's Treatment Administration Record [(TAR, or eTAR for electronic versions), commonly referred to as a treatment chart, is the report that serves as a legal record of physician ordered treatments applied at a facility by a health care professional. The TAR is a part of a patient's permanent record on their medical chart. The health care professional signs off on the record at the time that the treatment or device is administered] dated February 2024, revealed that the treatment to cleanse the area (right outer foot) with saline and apply Betadine and cover with a dry sterile dressing BID (twice per day) was not applied as prescribed by the podiatrist from February 13, 2024, through March 7, 2024.

At the time of the survey ending June 7, 2024, the facility was unable to provide documented evidence that staff applied the treatment as prescribed for 24 days, with the resident missing 48 treatments.

During an interview with the facility's wound care nurse on June 6, 2024, at 12:29 p.m., the nurse stated that the facility's licensed nursing staff erroneously entered the treatment application schedule for the right outer foot area into the eTAR and confirmed that the resident missed 24 days of treatments. The wound care nurse reported that when staff noticed that the treatments were not recorded in the eTAR that the order was reinitiated.

Further review of the clinical record revealed that the resident was admitted to the hospital on March 25, 2024, due to a change in condition, with coffee ground emesis [is vomit that looks like coffee grounds and is dark brown or black in color with a lumpy texture, which the appearance comes from old and coagulated blood in your gastrointestinal tract] and was readmitted to the facility on March 28, 2024.

A review of Resident 32's readmission wound assessment that was completed by a registered nurse (RN), dated March 28, 2024, at 2:15 p.m., revealed that the resident had a blood blister the right outer foot that measured 4.0 cm in length by 2.0 cm in width and no depth and orders to consult wound care specialists.

A review of the resident's TAR dated from March 28, 2024, to April 15, 2024, failed to reveal that treatments were applied to Resident 32's right outer foot blister.

The wound care specialist's initial wound evaluation dated April 15, 2024, revealed that Resident 32 had a stage 3 pressure ulcer [involve full-thickness skin loss potentially extending into the subcutaneous tissue layer] to the right outer foot that measured 3.0 cm in length by 3.0 cm in width by 0.20 cm in depth with no epithelial tissue, 25-49% granulation, 50-74% slough, with a moderate amount of serosanguinous exudate, and no odor present.

Further interview with the facility's wound care nurse on June 6, 2024, at 2:00 p.m., confirmed that there was no documented evidence that a treatment was applied to the resident's blistered area to the right foot upon readmission and that there was no documented evidence of weekly wound tracking completed by the facility until the wound care specialist assessed the area at a stage 3 pressure sore.

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

Plan of Correction - To be completed: 06/25/2024

F686E
Resident 32 treatments are being completed as per the physician's orders.

Current residents with podiatry consultations will be reviewed post visit to verify recommended treatment orders have been reviewed with the attending physician for orders. Admissions and readmissions will be reviewed during clinical meetings to verify treatment orders have been obtained for identified wounds.

The Director of nursing or designee will re-educate licensed nurses on the pressure ulcer policy and obtaining and completion of treatment orders.

The Director of Nursing or designee will conduct weekly audits x 4, then monthly x 2 of residents with podiatry consultations to verify recommended treatment orders have been reviewed with the attending physician for orders, and are being completed as per order.
The Director of Nursing or designee will conduct weekly x 4, then monthly x 2 audits of admissions/readmissions to verify treatment orders were obtained and completed for identified wounds. Results of the audits will be reviewed at the QAPI meetings.

Date of compliance will be June 25, 2024.

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

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.

§483.25(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 clinical record and select policy review, and staff interview it was determined that the facility failed to provide care and services designed to prevent potential complications with enteral tube feedings for one resident receiving an enteral feeding out of 19 residents sampled (Resident 56).

Findings include:

Review of a facility policy entitled "Enteral Feeding" provided by the facility on June 6, 2024, indicated that the facility will provide adequate nutritional support through enteral nutrition as ordered. According to the policy, staff caring for resident with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such clogging of the tube.

Review of Resident 56's clinical record revealed that the resident was admitted to the facility on July 12, 2021, with diagnoses, which included dysphagia (difficulty swallowing), epilepsy (neurological condition involving the brain that makes people more susceptible to having recurrent unprovoked seizures), and quadriplegia (paralysis of the arms and legs).

Resident 56 required a PEG tube [Percutaneous endoscopic gastrostomy (PEG) is an endoscopic medical procedure in which a tube (PEG tube) is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate [for example, because of dysphagia] for enteral feeding [enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements].

Review of Resident 56's plan of care, initiated on September 4, 2023, revealed a focus area related to the need for tube feeding/ potential for complications of feeding tube use related to dysphagia. Interventions planned were to administer medication and/or vitamin supplements as ordered, the tube feeding formula, hydration, and flushes as order. The care plan failed to identify the type and size of the PEG tube the resident required.

The resident had a physician order, dated February 16, 2024, for continuous tube feeding of Jevity 1.5 at 55 ml (milliliters) an hour, up at 4 PM and down at 12 PM until total volume of 1100 mL have been infused. An additional order dated February 15, 2024, was noted for an 83 mL water flush every 2 hours for a total of 996 mL every 24 hours (excludes medication flushes), and and an order dated July 24, 2023, to verify proper tube feed placement before medication administration, feeding and flushes, four times a day. The resident's physician orders failed to specify the type and size of PEG tube the resident required, and the amount of water flushes required before and after administration of medication.

Review of clinical record revealed documentation dated February 27, 2024, at 12:04 PM that the physician was notified that the resident's feeding tube was clogged. New orders were received to send the resident out of facility for feeding tube replacement.

The resident's clinical documentation revealed that on February 27, 2024, the resident returned to the facility without having her feeding tube replaced. According to the documentation, the resident arrived to the appointment late and the office was closed when she arrived. The appointment needed to be rescheduled.

Nursing documentation dated March 1, 2024, at 7:53 AM indicated that the resident left the facility to have her feeding tube replaced, 3 days from initial date the tube was noted to be blocked.

Review of Medication Administration Records dated February 2024 and March 2024 revealed that all ordered medications, feedings, and water flushes were administered via the feeding tube, despite documentation the nursing documentation on February 27, 2024, indicating that the resident's feeding tube was blocked and required replacement on February 27, 2024, through March 1, 2024.

Interview with Employee 2, licensed practical nurse on June 6, 2024, at 9:45 AM indicated that Resident 56's feeding tube was only "sluggish" and not fully blocked. According to Employee 2, medications, water flushes, and enteral feedings were able to be administered as ordered while awaiting for the feeding tube to be changed.

Interview with the Assistant Director of Nursing and Employee 2 on June 6, 2024, at 9:50 AM confirmed that there was no documentation that the resident's feeding tube continued to be functioning despite being "blocked." There was no evidence that the physician or the resident's representative were made aware that there was a delay in having the resident's feeding tube replaced due to late arrival for the resident's appointment on February 27, 2024.

Interview with the Nursing Home Administrator and Director of Nursing on June 7, 2024, at approximately 2:00 PM, confirmed that the facility failed to provide care and services designed to prevent potential complications associated with tube feedings and that the physician and RP were notified of changes accordingly.

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

28 Pa. Code 211.10 (c)(d) Resident care policies

Plan of Correction - To be completed: 06/25/2024

F693D
The deficient practice could not be retroactively corrected.

Current residents with sluggish or malfunctioning peg tubes will be reviewed during clinical meeting to verify that the resident had a replacement tube changed or documentation is present to support that the peg tube is sluggish but functioning. Current residents that have a delay in peg tube replacement will be reviewed during clinical meetings to verify that the physician and resident's representative have been notified.

The Director of Nursing or designee will reeducate licensed nurses on the Charting and Documentation policy.

The Director of Nursing or designee will conduct weekly x 4, then monthly x 2 audits of residents with sluggish or malfunctioning peg tubes to verify that the resident had a replacement tube changed or documentation is present if that the peg tube is sluggish but functioning, and those that had a delay in peg tube replacement have had the physician and resident's representative have been notified.

Date of compliance will be June 25, 2024.

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 observation, a review of temperature logs and staff interview it was determined that the facility failed to store drugs and pharmacy supplies under proper temperatures (2nd Floor Medication Room) and adhere to expiration/use by dates in one medication storage rooms out of two medication storage rooms.

Findings include:

Review of facility provided document entitled "Temperature Log for Refrigerator" indicated that medications and vaccines requiring refrigeration storage should be stored at a temperature range of 35 degrees Fahrenheit to 46 degrees Fahrenheit.

An observation of the 2nd Floor Medication Storage Room sink on June 6, 2024, at 8:52 a.m., revealed that there was a white putty-like substance smeared inside.

Observation of the 2nd Floor Medication Storage Room refrigerator revealed that the initial temperature reading on June 6, 2024, at 8:56 a.m., was at 28 degrees Fahrenheit and was below the acceptable temperature range 36 - 46 degrees Fahrenheit for medication storage. The freezer compartment had an accumulation of ice crystals covering the surface.

Observations of the 2nd Floor Medication Stock Medication cabinet, contained over the counter (OTC) medications and supplements, on June 6, 2024, at 11:55 a.m., revealed that the following medications were present in the cabinet and outdated:

Glucosamine and Chondroitin Triple Strength [nutritional supplement that may manage chronic joint pain and arthritis] 120 tablets had a manufacture's expiration date of February 2024
Ferrous Gluconate [iron supplement] 240 milligrams (mg) 100 tablets that had a manufacturer's best by date of October 2022
Sodium Bicarbonate [an antacid] 650 mg 1000 tablets that had a manufacture's expiration date of May 2024

Further observations on June 6, 2024, at 12:06 p.m., revealed that the 2nd Floor Medication Room refrigerator temperature was 28-degrees Fahrenheit and remained below the acceptable temperature range and the sink still had a white putty-like substance inside.

An interview with the Director of Nursing (DON) on June 7, 2024, at 11:38 a.m., confirmed that the 2nd Floor Medication Storage Room refrigerator was within proper temperatures, the med room area was not kept in a sanitary manner, and medications were kept beyond the expiration/use by date.

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

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

Plan of Correction - To be completed: 06/25/2024

F761D
The refrigerator was replaced in the second-floor medication room and temperatures have been maintained within range. The sink in the second-floor medication room was immediately cleaned. Expired medications were removed and disposed of.

An initial audit was completed in both medication storage rooms to verify that no expired medications were being kept beyond the expiration/use by dates, the medication storage room refrigerators are within proper temperatures, and the med room is being kept in a sanitary manner. Monitoring of the Medication storage rooms, refrigerator temperatures and medication expiration/use by dates is being monitored by the supervisor.

The Director of Nursing or designee will reeducate licensed nurses on the Medication Storage Policy.

The Director of Nursing or designee will conduct weekly x 4, then monthly x 2 audits of the medication storage rooms to verify that no expired medications were being kept beyond the expiration/use by dates, the medication storage room refrigerators are within proper temperatures, and the med room is being kept in a sanitary manner. Results of the audits will be presented at the QAPI meetings for review.

Date of compliance will be June 25, 2024.

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.

Observations:

Based on a review of clinical records and staff interview, it was determined that the attending physician failed to act upon pharmacist identified irregularities in the medication regimen of one of 19 residents sampled (Resident 46).

Findings include:

A review of the clinical record revealed Resident 46 was admitted to the facility on November 30, 2021, and had diagnoses that included dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), and bipolar disorder.

A review of February 2024 monthly pharmacy reviews revealed that the consultant pharmacist noted that the resident was prescribed as needed Ativan .5 mg for anxiety. Noting that per CMS guidelines all PRN psychotropic agents must be limited to a 14-day duration. This resident currently has an active PRN order for Lorazepam that requires change to meet these regulations.

The facility failed to provide written documentation of the attending physician's response to the drug irregularity and there was no documentation that the resident's physician acknowledged this identified pharmacy report.

The Director of Nursing on June 7, 2024, at approximately 10:00 AM and confirmed that the attending physician had not acted upon the pharmacy irregularity.

28 Pa. Code 211.9 (k) Pharmacy services.

28 Pa Code 211.5 (f) Medical records

28 Pa. Code 211.2 (d)(7) Medical director

Plan of Correction - To be completed: 06/25/2024

F756D
The facility cannot retroactively correct the deficient practice.

Current residents with recommendations by the pharmacy consultant will be reviewed during clinical meetings to verify that the attending physician acknowledged the pharmacy report.

The Director of Nursing or designee will reeducate licensed nurses and physicians on the Medication Regimen review policy and the requirement of the physician's response and documentation. Medication regime reviews will be reviewed during clinical meeting to verify the physician acknowledged the pharmacy report.

The Director of Nursing or designee will conduct monthly audits x2 of pharmacy recommendations to verify that the attending physician acknowledged the pharmacy report. Results of the audits will be presented at the QAPI meetings for review.

Date of compliance will be June 25, 2024

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

§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).

Observations:

Based on review of clinical records and facility-initiated transfer notices and a staff interview, it was determined that the facility failed to provide written notices of facility-initiated hospital transfers of residents, prepared in a language and manner that could be easily understood to three out of 19 residents reviewed (Resident 32, 56, and 87).

Findings include:

Regulatory requirements indicate that before a facility transfers or discharges a resident, the facility must 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.

A review of the clinical record revealed that Resident 32 required to be transferred to the hospital on March 25, 2024, and was readmitted to the facility on March 28, 2024.

A review of the facility provided "Facility Initiated Notice of Transfer or Discharge" revealed that the resident required an immediate transfer/discharge to an acute care facility on March 25, 2024, because the resident's urgent medical needs cannot be met in the facility due to (reason for transfer/discharge in terms understood by the resident and resident representative) "hematemesis" (vomiting blood). The facility failed to use language that could be easily understood by the resident or resident representative.

A review of the clinical record revealed that Resident 56 was transferred to the hospital on February 25, 2024, and returned to the facility that same day.

A review of the facility provided "Facility Initiated Notice of Transfer or Discharge" revealed that the resident required an immediate transfer/discharge to an acute care facility on February 25, 2024, because the resident's urgent medical needs cannot be met in the facility due to (reason for transfer/discharge in terms understood by the resident and resident representative) "eval and treat."

A review of the clinical record revealed that Resident 87 was transferred to the hospital on March 5, 2024 and later returned to the facility.

A review of the facility provided "Facility Initiated Notice of Transfer or Discharge" revealed that the resident required an immediate transfer/discharge to an acute care facility on March 5, 2024, because the resident's urgent medical needs cannot be met in the facility due to (reason for transfer/discharge in terms understood by the resident and resident representative) "abnormal vitals."

Interview with the Nursing Home Administrator on June 7, 2024, at approximately 1:30 PM confirmed that the facility failed to provide transfer information in a language that could be understood by both the resident and/or resident representative.

28 Pa. Code 201.29 (a)(c.3)(2) Resident rights

Plan of Correction - To be completed: 06/25/2024

F623B
The deficient practice could not be retroactively corrected.

Current residents requiring facility-initiated hospital transfers will have the transfer or discharge notice written in a language and manner that can be easily understood by the resident and the resident's representative.

The Director of Nursing or designee will re-educate licensed nurses on the Transfer/discharge policy and to document in a manner that can be easily understood by the residents and the resident's representative.

The Director of Nursing or designee will conduct weekly x 4 audits, then monthly x 2 of residents requiring facility-initiated hospital transfers to verify the transfer or discharge notice was written in a language and manner that can be easily understood by the resident and the resident's representative. Results of the audits will be reviewed at the QAPI meetings.

Date of compliance will be June 25, 2024.

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