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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

FOREST HILLS REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are 156 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.


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

Initial comments:
Based on a MedicareRecertification, State Licensure, and Civil Rights Compliance Survey completed on May 16, 2025, it was determined that Forest Hills Rehabilitation and Healthcare Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.21(b)(3)(i) REQUIREMENT Services Provided Meet Professional Standards:

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.

§483.21(b)(3) Comprehensive Care Plans
The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(i) Meet professional standards of quality.

Observations:

Based on clinical record review, facility policy review and staff interview, it was determined the facility failed to ensure that nursing services met professional standards of quality according to the Pennsylvania Code Title 49, Professional and Vocational Standards, by failing to implement nursing practices for the administration of an intravenous medication via central venous catheter for one of 36 residents reviewed (Resident 105).

Findings include:

According to the Pennsylvania Code Title 49, Professional and Vocational Standards Department of State, Chapter 21 State Board of Nursing, Chapter 21.145 Functions of the LPN (Licensed Practical Nurse) requires the following:
The LPN is prepared to function as a member of the health care team by exercising sound nursing judgement based on preparations, knowledge, skills, understandings and past experiences in nursing situations. The LPN participates in the planning, implementation and evaluation of nursing care in settings where nursing takes place. (b) The LPN administers medication and carries out the therapeutic treatment ordered for the patient in accordance with the following: (d) The Board recognizes codes of behavior as developed by appropriate practical nursing associations as the criteria for assuring safe and effective practice.

Chapter 21.145 b. IV therapy curriculum requirements:
(f) An LPN may perform only the IV therapy functions for which the LPN
possesses the knowledge, skill and ability to perform in a safe manner, except as
limited under 21.145 a (relating to prohibited acts), and only under supervision
as required under paragraph (1).
(1) An LPN may initiate and maintain IV therapy only under the direction
and supervision of a licensed professional nurse or health care provider authorized
to issue orders for medical therapeutic or corrective measures (such as a
CRNP, physician, physician assistant, podiatrist or dentist).

(g) An LPN who has met the education and training requirements of 21.145 b (relating to IV therapy curriculum requirements) may perform the following IV therapy functions, except as limited under 21.145 a and only under supervision as required under subsection (f):
(1) Adjustment of the flow rate on IV infusions.
(2) Observation and reporting of subjective and objective signs of adverse reactions to any IV administration and initiation of appropriate interventions.
(3) Administration of IV fluids and medications.
(4) Observation of the IV insertion site and performance of insertion site care.
(5) Performance of maintenance. Maintenance includes dressing changes, IV tubing changes, and saline or heparin flushes.
(6) Discontinuance of a medication or fluid infusion, including infusion devices.
(7) Conversion of a continuous infusion to an intermittent infusion.
(8) Insertion or removal of a peripheral short catheter.
(9) Maintenance, monitoring and discontinuance of blood, blood components and plasma volume expanders.
(10) Administration of solutions to maintain patency of an IV access device via direct push or bolus route.
(11) Maintenance and discontinuance of IV medications and fluids given via a patient-controlled administration system.
(12) Administration, maintenance and discontinuance of parenteral nutrition and fat emulsion solutions.
(13) Collection of blood specimens from an IV access device.

A review of a facility policy titled "Administering Medications by IV" last reviewed by the facility on April 22, 2025, revealed the facility is to verify the nursing staff scope of practice and competency requirements for this procedure with the State Nurse Practice Act.

Clinical record review revealed that Resident 105 was admitted to the facility on April 12, 2025, with diagnosis to include intracranial abscess and granuloma (collection of pus that develops in the brain due to an infection) and adult failure to thrive (gradual decline in health characterized by weight loss, decreased appetite, poor nutrition and inactivity), and was admitted to the facility with a PICC line (a peripherally inserted central catheter a long catheter introduced through a vein in the arm and passed through to the larger veins into the heart).

Physicians orders dated April 12, 2025, revealed an order to administer Ceftriaxone Sodium (antibiotic medication) Injection Solution Reconstituted 250 MG. Use 2 grams intravenously (IV) every 12 hours for abscess until May 9, 2025. Infuse 2 grams into a venous catheter (PICC) every 12 hours.

A review of the April 2025 Medication Administration Record (MAR) revealed that between April 13 through April 30, 2025, Employee 5, LPN, Employee 6, LPN, Employee 7, LPN, Employee 8, LPN, Employee 9, LPN, Employee 10, LPN, and Employee 14, LPN signed the MAR as administering the IV antibiotic medication to Resident 105 through the PICC line.

A review of the May 2025 MAR revealed that between May 1 through May 8, 2025, Employee 9, LPN, Employee 10, LPN, Employee 11, LPN, Employee 12, LPN, Employee 13, LPN, and Employee 14, LPN signed the MAR as administering the IV antibiotic medication to Resident 105 through the PICC line.

The facility was unable to produce any documentation verifying that these LPNs had completed the required IV therapy education and training in accordance with (b). There was no evidence of current competency validation, supervision documentation, or internal training specific to PICC line administration.

During an interview conducted on May 15, 2025, at approximately 10:50 AM, the Director of Nursing (DON) confirmed that the facility did not provide education or training regarding administration of medications through PICC lines to LPNs. The DON further stated that it was the facility's policy that only RNs were permitted to administer medications via PICC lines.

Despite this, multiple LPNs administered IV antibiotics through a central venous access device (PICC line) to Resident 105 over a 26-day period. There was no documented oversight by an RN or qualified healthcare provider, and no documentation existed confirming the LPNs met the education, training, or supervision requirements stipulated in the Pennsylvania Nurse Practice Act.

28 Pa. Code 201.20(a) Staff Development.

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

Plan of Correction - To be completed: 06/17/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
#1 This cannot retroactively be corrected.
#2 DON/Designee to conduct an audit of residents with central lines to verify RN is administering IV medication. Residents with Central lines had orders placed in their chart for RN to administer and assess site every shift.
#3 DON/Designee to reeducate nursing staff on Administering Medications by IV Policy.
#4 DON/Designee to conduct random weekly audits on 3 residents with IV medication orders to verify RN is documenting central line IV medication administration x 4 weeks then monthly x 2. Results will be reviewed at Monthly QAPI.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs:

§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(f) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.

Observations:

Based on clinical record review, payor source data, and resident and staff interview, it was determined the facility failed to provide timely and necessary dental services for two residents (Resident 48 and 103) and failed to provide routine dental for one resident (Resident 55) out of 36 residents reviewed who were Medicaid recipients.

Findings included:

A review of Resident 48's clinical record revealed the resident was admitted to the facility on April 28, 2021, with diagnoses to include Type 2 diabetes (trouble controlling blood sugar and using it for energy), chronic obstructive pulmonary disease (lung disease that blocks airflow and makes it difficult to breathe), and congestive heart failure (weakness of the heart that leads to build-up of fluid in the lungs and surrounding body tissues).

A quarterly Minimum Data Set Assessment (MDS a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 23, 2025, indicated the resident was moderately cognitively impaired with a BIMS score of 10 (brief interview for mental status, a tool to assess the residents' attention, orientation, and ability to register and recall new information, a score of 8-12 indicates moderate cognitive impairment).

Review of Resident 48's Dental Summary Report dated July 22, 2024, revealed the resident had an emergency dental exam due to complaints of pain and food getting stuck in his teeth. The probable cause of resident's complaints was identified as cavities and poor contact of teeth #30 and #31. Treatment recommendations were to extract decayed teeth.

Review of Resident 48's Dental Summary Report dated October 18, 2024, revealed the resident was scheduled for an extraction. The procedure was not performed as the resident was to receive an antibiotic one hour prior to the appointment and the facility failed to administer the medication. The dentist reported she spoke with the nurse and the nurse stated she was unaware that he was to be given an antibiotic. Extraction was to be reschedule for another visit.

At the time of the survey ending May 16, 2025, the facility was unable to provide documented evidence that a follow-up visit was rescheduled with the dentist for Resident 48 to undergo the extraction procedure as recommended by the dentist.

A review of Resident 103's clinical record revealed the resident was admitted to the facility on December 2, 2023, with diagnoses to include 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), type 2 diabetes, and moderate protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health).

A significant change of status MDS dated February 27, 2025 indicated the resident was severely cognitively impaired.

Nursing documentation dated November 12, 2024, at 9:36 PM revealed that the LPN (licensed practical nurse) reported that Resident 103 lost her upper denture. Her diet was downgraded to mechanical soft. The Physician and Resident Representative (RP) were notified.

Nurse documentation dated November 26, 2024, at 1:22 PM revealed that the RP was made aware the dentist was scheduled onsite to see the resident on December 9, 2024, for dentures.

Review of Resident 103's Dental Summary Report dated December 9, 2024, revealed the resident was not seen by the dentist as the resident was brought to the clinic and refused to be seen. The dentist indicated on the report that Resident 103 stated she did not want dentures.

There was no documented evidence the RP was notified of the outcome of dental visit and the resident's refusal for dentures.

Nursing documentation dated February 4, 2025, at 4:29 PM revealed the RP expressed concern that the resident never got her new dentures. The nurse discussed with the RP about the resident refusing to be seen by the dentist. The RP reported she believes it was a bad day for the resident and would like for the facility to try and have her seen by the dentist again. The RP stated that dentures were always very important to the resident, and she thinks she may eat more if she had dentures.

At the time of the survey ending May 16, 2025, the facility was unable to provide documented evidence that Resident 103 was scheduled for a dental appointment for dentures at the request of the RP on February 4, 2025.

A review of Resident 55's clinical record revealed the resident was admitted to the facility on May 26, 2023, with diagnoses to include metabolic encephalopathy (chemical imbalance in the blood that affects the brain which can cause loss of memory and difficulty coordinating motor tasks) and moderate protein-calorie malnutrition.
An annual MDS dated February 11, 2025, indicated the resident was cognitively intact with a BIMS of 14 (a score of 13-15 indicates cognitively intact responses).

During an interview with Resident 55 on May 13, 2025, at 12:00 PM she reported she has not seen a dentist in the past year while residing in the facility.

There was no documented evidence at the time of the survey ending May 16, 2025, the resident had been offered dental services in the past year.

During an interview on May 15, 2025, at approximately 11:00 AM the Director of Nursing (DON) was unable to produce documentation to demonstrate that routine dental was provided for Resident 55 or that timely and appropriate dental services were provided for Resident 48 and 103. The DON could not explain the delay in the dental referral or the prolonged timeline for dental services.

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

Plan of Correction - To be completed: 06/17/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
#1Resident 48, 103 and 55 were added to the dental service list for visit.
#2 DON/Designee to conduct an audit of when residents were last seen by dental services. Those with issues or who are overdue for a visit were added to the dentist list.
#3 DON/Designee to reeducate nursing staff on the Dental Services Policy.
#4 DON/Designee to conduct random weekly audits on 8 residents to ensure they are being seen by dentist timely and orders from consult papers are carried about weekly x 4 weeks then monthly x 2. Results will be reviewed at Monthly QAPI.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on review of clinical records, select facility policy, and resident and staff interview, it was determined the facility failed to consistently provide restorative nursing services as planned to maintain mobility for one resident (Resident 141) out of 36 residents sampled.

Findings include:

Review of the facility Restorative Nursing Services Policy last reviewed April 22, 2025, indicated residents will receive restorative nursing care as needed to help promote optimal safety and independence. Residents may be started on a restorative nursing program upon admission, during the course of stay, or when discharged from rehabilitative care. Restorative goals and objectives are individualized and resident-centered and are outlined in the resident's plan of care. The resident or representative will be included in determining goals and plan of care.

Review of the clinical record revealed that Resident 141 was admitted to the facility on April 27, 2023, with diagnoses which include vascular dementia (a form of dementia caused by an impaired supply of blood to the brain), diabetes, and congestive heart failure (chronic condition in which the heart does not pump blood as well as it should).

Review of an annual Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated February 28, 2025, indicated the resident had a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 10 (a score of 8-12 indicates moderate cognitive impairment) and the resident had the ability to walk 10 feet with supervision or touching assistance, but refused to walk 50 feet or 150 feet in a hall or similar space.

During an interview with Resident 141 on May 13, 2025, at approximately 12:30 PM the resident stated that he feels like he is getting weaker and is not being ambulated by staff on a consistent basis.

Review of Resident 141's Physical Therapy Discharge Summary dated November 29, 2024, revealed the resident met his goal to ambulate 150 feet using a RW (rolling walker- wheeled mobility aid designed to provide support and stability for individuals with difficulty walking, featuring wheels for easy movement without lifting) with stand by assistance. A restorative nursing program for ambulation with RW 150 feet with contact guard and wheelchair follow was recommended for the resident.

Review of Resident 141's care plan in effect at the time of the survey ending May 16, 2025, failed to reveal as per facility policy an individualized and resident-centered care plan with restorative goals and objectives to address the resident's restorative ambulation program which was recommended by therapy.

Review of Resident 141's December 2024 through May 14, 2025, Task Documentation Reports revealed a Restorative Ambulation Task to ambulate the resident 150 feet with RW and wheelchair follow on the 7:00 AM to 3:00 PM shift. Further review of the reports revealed that staff documented resident refusal or NA (not applicable) on most days.

Further review of the clinical record revealed no documented evidence the resident's restorative ambulation program was reevaluated based on the resident's noted refusals and not being offered to ambulate as indicated by the documentation of the nurse aide on the resident's Task Documentation Reports.

During interview with Resident 141 in the presence of Employee 3 (RN Unit Manager) on May 15, 2025, at approximately 10:00 AM the resident confirmed he is not being provided the opportunity to ambulate.

Interview with the Director of Nursing on May 15, 2025, failed to provide documented evidence that Resident 141's restorative ambulation program was implemented and being monitored in a manner to ensure the resident's goals for ambulation are met to the extent possible as per facility policy.

28 Pa. Code: 211.5(f)(viii) Medical records

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

Plan of Correction - To be completed: 06/17/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
#1 Resident #141 restorative ambulation program was evaluated
#2 DON/Designee to conduct an audit of residents on restorative ambulation program to verify programs are implemented and monitored.
#3 DON/Designee to reeducate nursing staff on Restorative Nursing Services Policy.
#4 DON/Designee to conduct 5 random weekly audits of residents' restorative ambulation programs to verify they are being evaluated and monitored with programs and care plans updated as needed weekly x 4 weeks then monthly x2 Results will be reviewed at Monthly QAPI.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect:

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.

§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Observations:

Based on review of the facility's abuse prohibition policy, clinical records, information submitted by the facility, and select investigative reports and staff interviews, it was determined the facility failed to assure that one resident (Resident 28) out of 36 sampled were free from physical abuse perpetrated by another resident (Resident 133).

Findings include:

A review of facility policy titled "Facility Abuse Policy" last reviewed by the facility on April 22, 2025, revealed it is the policy of the facility to not tolerate abuse, neglect, mistreatment, exploitation of residents, or misappropriation of resident property by anyone. The policy defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

A review of Resident 178's clinical record revealed he was admitted to the facility on January 3,2025, with a diagnosis which included Multiple Sclerosis (a chronic autoimmune disorder that affects the central nervous system) and Cellulitis (a bacterial infection that affects the inner layers of the skin).

A review of the resident's Quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated February 20,2025, indicated the resident was severely cognitively impaired With a BIMS score of 5 (Brief Interview for Mental Status - a tool to assess cognition, a score of 0-7 indicates severe cognitive impairment).

A review of Resident 133's clinical record revealed the resident was admitted to the facility on January 24,2024, with diagnoses which included unspecified sequelae of cerebral infarction (refers to the long term affects and complications that can occur after a stroke ), aphasia (a communication disorder that results from damage to parts of the brain that is responsible for language and affects a person's ability to speak) and vascular dementia (a type of dementia caused by brain damage from impaired blood flow to the brain ).

A review of the resident's Quarterly Minimum Data Set Assessment dated March 6, 2025, indicated the resident had impaired cognitive function. The assessment indicated Resident 133 had a BIMS score of 99 (Brief Interview for Mental Status - a tool to assess cognition, a score of 99 indicates the resident did not provide or was unable to provide the answers to complete this section).

Nursing notes from December 2024 through January 2025 documented a pattern of physically aggressive behaviors, including yelling, throwing items, banging fists against the medication cart, and exhibiting threats to others.

On January 3, 2025, at 10:00 PM, staff responded to loud yelling from the shared room of Resident 133 and another resident. Resident 133 was removed and placed on one-to-one supervision. Subsequently, a nursing note on January 4, 2025, at 12:26 AM documented that Resident 133 allegedly struck his roommate, Resident 178, twice in the chest with a closed fist.

Review of the mandatory abuse report dated for January 4, 2025, revealed staff responded to the room occupied by Residents 178 and 33 when they heard yelling. Resident 33 was found at the bedside of Resident 178 and noted to be yelling. Resident 133 was immediate removed to the hallway. Further review revealed Resident 178 stated he was laying in his bed when Resident 133 came over and started to yell at him, then punched him twice, once in the arm and once in the chest. Resident 178 was assessed with no injuries to be noted.

A review of nursing documentation revealed a nursing note dated January 8,2025 at 3:38 PM revealed the Interdisciplinary Team met to discuss Resident 133's one to one supervision status. Resident 133's agitation and yelling were noted to be during the 3:00 PM to 11:00 PM shift and was noted to be calm and sleeping during the 11:00 PM to 7:00 AM shift. Resident 133 was to remain a one-to-one supervision for both day and evening shifts but was changed to every 15-minute checks for the night shift.

Review of Resident 133's care plan dated March 1, 2024, and revised February 3,2025, identified issues related to behaviors of refusing showers, care and medications. Continued review revealed Resident 133 was identified having behaviors of being aggressive towards staff and other residents, throwing items (bed side table, cabinets, chairs), slamming doors, banging his head off the wall or kicking the side rails, and purposely placing himself on the floor.

Further review of the care plan revealed interventions to include, monitor behavior episodes and attempt to determine underlying cause, attempt to redirect resident when exhibiting behaviors, re-approach resident when behaviors have deescalated, attempt distraction during behavioral episodes by offering a coloring activity, converse about baseball, offer a snack, assist with getting the resident to a quiet area to self soothe, take resident for a walk.

A new intervention dated April 11, 2025, stated that Resident 133 was to receive 1:1 observation on the day and evening shifts and every 15-minute checks overnight.

A review of Resident 28's clinical record revealed the resident was admitted to the facility on February 4, 2016, with diagnoses which included major depressive disorder (a mood disorder characterized by persistent feeling of sadness and loss of interest in activities once enjoyed). and essential hypertension (high blood pressure).

A review of the resident's Quarterly Minimum Data Set Assessment dated January 21, 2025, indicated the resident was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status - a tool to assess cognition, a score of 13-15 indicates cognition was intact).

On April 16, 2025, at 3:30 AM, a physical altercation occurred between Resident 133 and Resident 28 in their shared room. According to nursing documentation, Resident 133 threw water and a cup at Resident 28 near the bathroom door, then slapped Resident 28 in the face. Resident 28 attempted to disengage but returned the slap before staff intervened. Both residents were assessed, and no physical injuries were documented. Resident 133 was relocated to a different room following the incident.

A review of Resident 133's hourly observation log for April 16, 2025, revealed inconsistencies. CNA documentation indicated that the resident was observed sleeping at both 3:00 AM and 4:00 AM. However, this contradicts the timeline of the incident, and no evidence was provided that every-15-minute checks were performed as required by the care plan.

An interview with the Director of Nursing (DON) conducted on May 16, 2025, at 11:00 AM confirmed the facility did not maintain consistent or effective supervision of Resident 133 during the overnight shift and failed to ensure safety protocols were followed. The DON acknowledged that the lack of supervision directly contributed to a slap in the face of Resident 28.

28 Pa. Code 201.14(a) Responsibility of licensee

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

28 Pa. Code 201.29(a)(c) Resident Rights

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

Plan of Correction - To be completed: 06/17/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
#1 This cannot retroactively be corrected.
#2 DON/Designee to conduct an audit of residents on safety checks to verify consistency in documentation. IDT to discuss residents behaviors/ status of safety checks during weekly IDT risk meeting. DON/Designee to implement new safety observation papers.
#3 DON/Designee to reeducate nursing staff on Abuse Policy and new implemented observation sheet.
#4 DON/Designee to conduct random weekly audits on 3 residents with safety checks to verify consistency / accuracy in safety documentation x 4 weeks then monthly x 2. Results will be reviewed at Monthly QAPI.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on clinical record review, observations, and resident and staff interviews it was determined the facility failed to provide the necessary staff assistance with activities of daily living to maintain good personal grooming for residents dependent on staff assistance for nail care for two of five residents sampled (Residents 25 and 141).

Findings include:

Review of the clinical record revealed that Resident 25 was admitted to the facility on May 1, 2024, with diagnoses which include dementia (group of symptoms affecting intellectual and social abilities severely enough to interfere with daily functioning).

Review of a quarterly Minimum Data Set Assessment (MDS- a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated May 5, 2024, indicated the resident had a BIMS score (Brief Interview for Mental Status - a tool to assess cognitive function) of 2 (a score of 0-7 indicates severe cognitive impairment) and required substantial/maximal assistance (staff does more than half the effort) with personal hygiene.

Observations of Resident 25 conducted on May 13, 2025, at 12:15 PM and May 15, 2025, at 9:45 AM revealed the fingernails on the resident's left hand were dirty with a build-up of a dark colored debris under the nails.

Interview with employee 2 (Registered Nurse Regional Consultant) on May 15, 2025, at 9:45 AM confirmed that Resident 25's fingernails were dirty.

Review of the clinical record revealed that Resident 141 was admitted to the facility on April 27, 2023, with diagnoses which include vascular dementia (a form of dementia caused by an impaired supply of blood to the brain).

Review of an annual MDS dated February 28, 2025, indicated the resident had a BIMS score of 10 (a score of 8-12 indicates moderate cognitive impairment) and required substantial/maximal assistance for personal hygiene.

Observations of Resident 141 on May 13, 2025, at 12:50 PM and May 15, 2025, at 9:50 AM revealed that the fingernails on the resident's right hand were long and there was a build-up of dark colored debris under the nails.

During interview with Resident 141 on May 15, 2025, at 9:50 AM the resident revealed that he is able to trim the fingernails on his left hand but does not have enough strength to trim the fingernails on his right hand.

Interview with the assistant director of nursing on May 15, 2025, at approximately 10:30 AM confirmed that staff were to provide residents' nail care to maintain good personal grooming and hygiene.

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

Plan of Correction - To be completed: 06/17/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
#1 Residents # 25 and # 141 were provided fingernail care.
#2 DON/Designee to conduct an audit of residents fingernails; Staff provided nailcare to those identified the need to be cut.
#3 DON/Designee to reeducate nursing staff on Care of Fingernails/Toenails Policy.
#4 DON/Designee to conduct random weekly audits of 10 residents fingernails to ensure clean and maintained weekly x 4 weeks then monthly x2. Results will be reviewed at Monthly QAPI.

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 a review of clinical records, select facility policy, and staff interviews it was determined the facility failed to timely provide care and services, consistent with professional standards of practice, to promote healing of pressure ulcer development for one of four residents reviewed. (Resident 10)

Findings:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk.

The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

Review of the facility Pressure Ulcer Policy last reviewed April 22, 2025, indicated staff will examine the skin of a new admission for ulcerations or alterations in skin. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings, and application of topical agents if indicated for the type of skin alteration.

Review of the clinical record revealed that Resident 10 was admitted to the facility on December 31, 2024, with diagnoses which included multiple sclerosis (chronic autoimmune disease that affects the brain and spinal cord) and a pressure ulcer to the right hip.

A review of the Admission Evaluation dated December 31, 2024, noted that Resident 10 required the assistance of two staff for bed mobility. However, there was no documented evidence that a turning and repositioning program was initiated upon admission, despite the presence of an existing pressure ulcer and the resident's dependence on staff for bed mobility.

Review of Resident 10's January Task Documentation Report revealed that a turning and repositioning every two hours program was not implemented until January 3, 2025 (three days after admission).

Review of a Wound Evaluation note dated December 31, 2024, upon admission to the facility documented the presence of a Stage 4 (full-thickness skin and tissue loss with exposed bone, muscle, or tendon) pressure ulcer on the right hip which measured 1 cm length by 1cm width by 0.8 cm depth with undermining (wound edges are separated from the surrounding healthy tissue, creating a "pocket" beneath the wound surface) 1 cm at 12 o'clock, no odor, 20% granulation (tissue that will fill in a wound that is healing), 30% slough (dead tissue separating from living tissue, a mass of dead tissue), and no pain. The note indicated a new treatment was ordered.

However, further review of the clinical record revealed no physician orders for wound treatment to the Stage 4 pressure ulcer dated December 31, 2024.

The first available treatment order for the right hip pressure ulcer was dated January 3, 2025 (three days after the resident was admitted to the facility), noted an order to cleanse right hip with soap and water, pat dry, pack loosely with inch iodoform (antiseptic agent) gauze (type of wound packing where a sterile gauze strip is impregnated with iodoform and used to fill the wound cavity) and cover with bordered dressing once daily.

An interview conducted with Employee 4, Registered Nurse Wound Care Nurse, on May 16, 2025, at approximately 11:00 AM, failed to produce documented evidence that a wound treatment was implemented upon admission as indicated in the Wound Evaluation dated December 31, 2024.

During an interview conducted with the Director of Nursing on May 16, 2025, at approximately 11:30 AM, the DON was unable to provide documentation that timely wound care and pressure ulcer interventions were initiated to promote healing of Resident 10's Stage 4 pressure ulcer upon admission.

28 Pa. Code 211.10(d) Resident care policies

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

28 Pa. Code 211.5(f)(i)(viii) Medical records.

Plan of Correction - To be completed: 06/17/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
#1 Resident # 10 has a turning and repositioning program and treatment order in place for pressure areas.
#2 DON/Designee to conduct an audit of residents with pressure ulcers over the last 30 days to verify turning and repositioning program and treatments are ordered.
#3 DON/Designee to reeducate nursing staff On the Pressure Ulcer Skin Breakdown and Prevention of Pressure Injuries policies
#4 DON/Designee to conduct random weekly audits of 5 residents who have pressure ulcers to verify a timely turning and repositioning program, and treatment order is in place weekly x 4 weeks then monthly x 2. Results will be reviewed at Monthly QAPI.

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, review of select facility policy and clinical records, and staff interviews, it was determined the facility failed to adhere to acceptable storage and labeling for multi-dose medications in one of four medication carts observed (Master Hall Three).

Findings include:

Review of the facility policy titled "Medication Labeling and Storage" last reviewed by the facility April 22, 2025, indicated that multi-use vials that have been opened or accessed (e.g. needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.

An observation of the medication cart located on Master Hall Three unit on May 14,2025 at 9:20 AM, in the presence of Employee 15 (Registered Nurse) of medication stored in the medication cart, revealed two (2) multi-dose insulin pens of Insulin Aspart ( a rapid acting insulin medication used to lower blood sugar ) and Insulin Glargine (a long acting insulin medication used to lower blood sugar) that had been opened and available for use, but not dated when initially opened.

An interview with Employee 15 (RN) on May 14, 2025 at 9:30 AM confirmed both multi dose insulin pens: Insulin Aspart and Insulin Glargine were opened, and available for use, and not dated.

Interview with the Director of Nursing (DON) on May 14,2025, at approximately 11:00 AM, confirmed the facility failed to adhere to acceptable storage and labeling practices for multi-dose medications.

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

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

Plan of Correction - To be completed: 06/17/2025

This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies
#1 Employee # 15 dated the opened insulin on 3 Master medication cart.
#2 DON/Designee to conduct an audit of medication carts to verify opened insulin is dated.
#3 DON/Designee to reeducate nursing staff on Medication Labeling and Storage Policy.
#4 DON/Designee to conduct random weekly audits of 8 medication carts to verify opened insulin is dated weekly x 4 weeks then monthly x2. Results will be reviewed at Monthly QAPI.

§ 201.19(3) LICENSURE Personnel policies and procedures.:

(3) Documentation of credentials, which shall include, at a minimum, current certification, registration or licensure, if applicable, for the position to which the employee is assigned.

Observations:

Based on a review of nurse aide registration records and staff interview it was determined the facility failed to ensure documentation of a current nurse aide registry status for one employee.

Findings include:

A review of the facility's nurse aide registration records identified that Employee 1 (nurse aide) was employed as a nurse aide on the 11:00 PM to 7:00 AM shift, and according to schedules was on duty on February 5, 2025, and February 8, 2025, although the employee failed to renew enrollment with the Pennsylvania Nurse Aide Registry. Employee 1 (NA)'s registration expired as of February 3, 2025.

An interview with the director of nursing (DON) on May 15, 2025, at approximately 1:00 PM confirmed that timely nurse aide registry renewal is a condition for employment at the facility. The DON confirmed the employee worked at the facility although the employee had not renewed her registry status.

Plan of Correction - To be completed: 06/17/2025

#1 This cannot retroactively be corrected
#2 DON/Designee to conduct an audit of licensed nurses and certified aids certificates to identify any that are expired. Implemented automated emailed and SMS alerts to notify employees at 30, 60 and 90 days before expiration date. Employee to show proof of renewal at least 7 days before expiration. Employee will be removed from the schedule the day before expiration date on License/certification, if no proof of renewal shown.
#3 DON/Designee to reeducate HR and nursing staff on credentialing of Nursing Service Personnel Policy.
#4 DON/Designee to conduct random weekly audits of 5 license and 5 certifications to check expiration dates x 4 weeks then monthly x 2. Results will be reviewed at Monthly QAPI.

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