Pennsylvania Department of Health
TWIN PINES HEALTH CARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TWIN PINES HEALTH CARE CENTER
Inspection Results For:

There are 111 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.


TWIN PINES HEALTH CARE CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure and Civil Rights Compliance survey completed on March 7, 2025, it was determined that Twin Pines Health Care Center was not in compliance with the following requirements of 42 CFR 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as it relates to the Health portion of the survey process.

Plan of Correction:

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

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

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based upon clinical record review and interview, it was determined the facility failed to ensure residents' physician was notified regarding a resident and failed to ensure residents' physician was notified of a significant weight loss for two of two residents reviewed (Resident 72 and Resident 104).

Findings include:

Review of Resident 72's clinical progress notes dated July 27, 2024, at approximately 5:45 a.m. revealed Resident 72 suffered a fall out of bed and was found laying on the floor on resident's right side.

Further review of Resident 72's clinical progress notes revealed Resident 72 complained of pain upon leg movement. After assessment by facility staff, Resident 72 was returned to bed.

Review of clinical documentation failed to reveal evidence that Resident 72''s physician or nurse practitioner were notified of the fall that occurred at 5:45 a.m.

Further review of Resident 72's progress notes dated July 27, 2024, at 7:20 a.m. revealed Resident 72 was unable to bear weight and continued to complain of pain in the left lower extremity. Resident 72's nurse practitioner was then notified of the fall that had occurred at 5:45 a.m. and an x-ray was ordered at that time.

Review of Resident 72's x-ray report dated July 27, 2024, revealed Resident 72 sustained a fracture of the left femoral (large bone in leg) neck and was subsequently transferred to an acute care facility.

Interview with the Director of Nursing on March 7, 2025, at 10:00 a.m. confirmed Resident 72's physician was not notified at the time of Resdient 72's fall with injury.

28 Pa. Code 211.12(d)(1)(2)(3) Nursing Services
Previously cited 4/5/2024

Plan of Correction - To be completed: 04/09/2025

1. A care conference was held for R72 and R104 to ensure they were aware of their current plan of care.

2. All residents with a change in condition or services have the potential to be affected. On 3/24/2025 the Director of Nursing (DON) and/or designee reviewed nursing notes from date of survey exit to ensure that any changes had corresponding resident/responsible party (RP) notification documented. If necessary, the change was discussed with the resident and/or their RP; and the discussion noted.

3. To prevent the potential for reoccurrence the DON and/or designee will educate all licensed staff on documentation pertaining to service changes with emphasis on notating resident and/or RP notification.

4. To monitor and maintain ongoing compliance the DON and/or designee will review resident progress notes 5 times a week for 3 months to ensure resident status change documentation also includes resident/RP notification. If an issue is identified the resident and/or RP will be notified of the change, the discussion noted, and the responsible person immediately educated. Audit results will be forwarded to the facility QAPI committee for further review and recommendation.

483.20(b)(1)(2)(i)(iii) REQUIREMENT Comprehensive Assessments & Timing:

§483.20 Resident Assessment
The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity.

§483.20(b) Comprehensive Assessments
§483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following:
(i) Identification and demographic information
(ii) Customary routine.
(iii) Cognitive patterns.
(iv) Communication.
(v) Vision.
(vi) Mood and behavior patterns.
(vii) Psychological well-being.
(viii) Physical functioning and structural problems.
(ix) Continence.
(x) Disease diagnosis and health conditions.
(xi) Dental and nutritional status.
(xii) Skin Conditions.
(xiii) Activity pursuit.
(xiv) Medications.
(xv) Special treatments and procedures.
(xvi) Discharge planning.
(xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS).
(xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts.

§483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs.
(i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.)
(iii)Not less than once every 12 months.

Observations:

Based on clinical record reviews, interviews with staff and residents, it was determined that the facility failed to conduct an accurate comprehensive assessment for one of 32 residents reviewed. (Resident 51)

Findings include:

Clinical record review revealed a quarterly assessment MDS (a minimum data set, which was part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid-certified nursing homes) dated January 1, 2025, that indicated Resident 51 obtained a stage 2 pressure ulcer (a shallow, open sore or an intact or ruptured blister, with a red or pink wound bed caused by prolonged exposure to pressure) while residing in the facility.

Further review of Resident 51's MDS revealed a Brief Interview for Mental Status (BIMS) score of 15.

Review of Resident 51's clinical records revealed wound care notes dated February 18, 2025, documenting the resident had a skin tear (a traumatic wound that occurs when the top layer of skin separates from the deeper layers) on his/her inner thigh that was being treated with Medihoney (a typical first aide and wound care product) and dressing.

Review of Resident 51's clinical records revealed wound care notes dated February 25, 2025, documenting the resident had a skin tear on inner thigh with treatment changed to skin prep.

Further review of Resident 51's clinical records revealed wound care notes dated March 4, 2025, documenting the resident had a skin tear on inner thigh that was improving.

Review of Resident 51's clinical records revealed that the resident did not have orders for treatment of a stage 2 pressure ulcer.

Review of Resident 51's clinical records revealed a care plan last revised on November 15, 2024, documenting the resident is at risk for skin injury related to immobility, paraplegia (paralysis to lower half of body), a history of stage 4 wounds, and a history of tendon release surgery (procedure used to treat muscular skeleton conditions).

Interview of Resident 51 on March 5, 2025, at 9:37 am revealed they currently did not have a pressure ulcer. Resident 51 was unable to state the last time he/she had a pressure ulcer.

Interview with Register Nurse Employee E4 on March 6, 2025, at 11:58 AM revealed the resident did not have a stage 2 pressure ulcer at the time of the MDS assessment and the resident only had a skin tear.

Interview with the MDS Coordinator, Employee E5 on March 6, 2025, at 2:05 p.m., confirmed a data entry error was made on Resident 51's MDS and the resident did not have a facility acquired pressure ulcer at the time of its completion on January 1, 2025.

28 Pa Code 211.12 (d)(1) Nursing services

Plan of Correction - To be completed: 04/09/2025

1. A Minimum Data Set (MDS) correction was made and submitted for R51 on 3/6/2025 to ensure a wound was accurately coded within Section M.

2. All residents with wounds have the potential to be affected. On 3/22/2025 the Registered Nurse Assessment Coordinator (RNAC) and/or designee conducted an audit to ensure all identified residents had Section M of their MDS accurately coded. If necessary a correction was made, and the MDS resubmitted.

3. To prevent the potential for reoccurrence the Regional Reimbursement Coordinator will educate the facility RNAC on MDS coding with emphasis on Section M requirements.

4. To monitor and maintain ongoing compliance the NHA and/or designee will audit 5 random residents 1 time a month for 3 months to ensure accurate completion of section M of the MDS. If an issue is observed the issue will be corrected, the MDS resubmitted, and the responsible person reeducated. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.

Observations:

Based on observations, clinical record review, and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of two residents reviewed regarding oxygen use. (Resident R6)

Findings include:

Resident R6's clinical record revealed that the resident was admitted to the facility on January 14, 2025, with diagnoses of acute on chronic systolic heart failure (long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), chronic obstructive pulmonary disease, unspecified (a progressive lung disease that makes it difficult to breathe due to obstruction of airflow).

Review of Resident R6's Minimum Data Set (MDS - a periodic assessment of care needs) upon admission, revealed a Brief Interview for Mental Status (BIMS) of 15 which indicated that the resident was cognitively intact.

On March 4, 2025, Resident R6 was observed in their room using supplementary oxygen.

Review of Resident R6's clinical records revealed the following order "administer oxygen via nasal cannula continuously at 2 liters/minute".

A review of the current care plan, dated January 21, 2025, found no evidence of a comprehensive, person-centered plan of care addressing oxygen interventions.

During an interview on March 7, 2025, at 11:23 a.m., the Director of Nursing (DON), confirmed that Resident R6 had an active order for continuous oxygen and acknowledged that no comprehensive care plan had been developed to address oxygen interventions.

28 Pa. Code 201.14 (a) Responsibility of Licensee

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

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

Plan of Correction - To be completed: 04/09/2025

1. R6 care plan updated to include oxygen usage.

2. All residents requiring oxygen have the potential to be affected. On 3/25/2025 the DON and/or designee reviewed resident care plans to ensure that oxygen use was represented. Where necessary the plan of care was updated.

3. To prevent the potential for reoccurrence the DON and/or designee will educate licensed staff on care planning with emphasis on oxygen management.

4. To monitor and maintain ongoing compliance the DON/designee will monitor resident orders 1 time weekly for 3 months to ensure that all new oxygen orders are also represented in the resident's care plan. If necessary, the care plan will be updated and the responsible person immediately reeducated. The results of the audit will be forwarded to the facility QAPI committee for further review and recommendations as needed.

483.21(c)(2)(i)-(iv) REQUIREMENT Discharge Summary:

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.

Observations:

Based on closed clinical record review and interviews with staff, it was determined the facility failed to ensure discharge instructions included all necessary information, including a recapitulation of stay, resident status, medication reconciliation, living arrangements, follow-up care and individualized care instructions, for a one of three closed records reviewed (Resident 111).

Findings include:

Clinical record review for Resident 111 revealed a Nursing Progress Note, dated December 16, 2024, at 5:19 a.m. which indicated that the resident was admitted to Chester County Hospital. Admitting diagnosis was unknown at the time. The hospital nurse was unable to disclose information due to resident request. No further information was noted concerning Resident 111's hospital discharge.

Continued review of Resident R111's clinical records revealed no discharge summary documenting the resident's personal belongings were returned, their primary physician information, pharmacy information, housing arrangements, medication list, medication education, medication disposition, disease management education, emergency information, brief medical history, current treatment and therapies, scheduled appointments and tests or contact information for the nursing facility. There was no indication that the information was provided to the resident or his/her family.

Interview conducted with Director of Nursing (DON) on March 7, 2025, at 10:05 a.m. when the above information was presented the DON stated the resident had no personal belonging to return or medications to be reconciled and confirmed that no additional discharge instruction information was available for review at the time of the survey for Resident R111.

28 Pa Code 201.25 Discharge policy

28 Pa Code 211.11(e) Resident care plan

Plan of Correction - To be completed: 04/09/2025

1. R111 no longer resides within the facility.

2. All residents who have discharged from the facility have the potential to be affected. On 3/25/2025 the Director of Nursing (DON) and/or designee audited all discharges from date of survey exit to ensure a discharge summary with plan, medication reconciliation, and personal inventory dispersal were present. If necessary, the information was documented and the affected patient and/or their responsible party (RP) notified.

3. To prevent the potential for reoccurrence the DON and/or designee educated licensed staff on documentation requirements pertaining to resident discharge.

4. To monitor and maintain ongoing compliance the DON and/or designee will review 3 discharge residents 1 time a week to ensure documentation compliance was maintained. If an issue was observed it will be corrected, and the responsible person immediately reeducated. Findings will be presented to facility QAPI for continued review and recommendation.

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 upon clinical record review and interview, it was determined the facility failed to ensure a fluid restriction, ordered by resident's physician, was monitored for one of one resident reviewed (Resident 99).

Findings include:

Review of Resident 99's diagnosis list revealed diagnoses including congestive heart failure (CHF - excessive body/lung fluid caused by a weakened heart muscle) and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability).

Review of Resident 99's clincal record revealed the resident was admitted to the facility on February 20, 2025 with an order for a 2-liter (2L) a day fluid restriction.

Review of Resident 99's clinical record failed to reveal evidence that nursing was monitoring Resident 99's daily 2L fluid restriction.

Interview with the Director of Nursing on March 7, 2025, at 9:35 a.m. confirmed that nursing was not monitoring Resident 99's 2L fluid restriction as ordered by the physician. This interview further revealed that, per the Director of Nursing, upon review Resident 99 should not have been on a fluid restriction from admission and the fluid restriction was removed on March 7, 2025.

28 Pa. Code 211.12(d)(1)(2)(3) Nursing Services
Previously cited 4/5/2024

Plan of Correction - To be completed: 04/09/2025

1. Fluid restriction order for R99 was reviewed by medical doctor (MD) and discontinued.

2. All residents requiring fluid restrictions have the potential to be affected. On 3/25/2025 the DON and/or designee audited fluid restriction documentation to ensure that resident consumption was documented and that if it was less than; or exceeded, ordered parameters the MD was made aware and new orders received.

3. To prevent the potential for reoccurrence the DON and/or designee will educate all licensed and certified staff on fluid restrictions with emphasis on how to document consumption.

4. To monitor and maintain ongoing compliance, the DON/designee will audit 2 random residents with fluid restriction orders 1 time weekly for 3 months to ensure that fluid consumption is documented and that deviations from the restriction parameters are reported to the MD. If an issue is observed it will be reviewed with the physician, new orders received, and the responsible person reeducated. Findings will be presented to facility QAPI for continued review and recommendation.

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

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

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

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

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

Observations:

Based upon clinical record review and interview, it was determined the facility failed to ensure adequate monitoring of a resident with a significant weight loss (Resident 104).

Findings include:

Review of Resident 104's diagnosis list revealed diagnoses including protein-calorie malnutrition and adult failure to thrive.

Review of Resident 104's weight summary revealed the resident weighed 136.6 pounds on December 8, 2024, and weighed 128.4 pounds on December 22, 2024, indicating a 6 percent weight loss in 14 days.

Review of Resident 104's clinical record failed to reveal evidence that Resident 104's physician was not notified of Resident 104's significant weight loss.

Review of clinical documentation revealed no re-weight was obtained to ensure accuracy of the weight loss.

Interview with Licensed Employee E3 on March 7, 2025, at 9:38 a.m. revealed a re-weight should have been obtained to ensure accuracy of the weight loss.

Further interview with Licensed Employee E3 on March 7, 2025 confirmed that Resident 104's physician was not notified of the weight loss and the loss was not address.

28 Pa. Code 211.12(d)(1)(2)(3) Nursing services
Previously cited 4/5/2024

Plan of Correction - To be completed: 04/09/2025

1. R104's weight trend was reviewed with the MD on 3/25/2025. Recorded weight was identified as placed in error as previous weights and all subsequent weights were similar. No new orders.

2. All residents with a weight loss have the potential to be affected. On 3/24/2025 the DON and/or designee observed weights to determine if weight loss was observed and addressed by MD or dietitian. Disparities were reviewed with MD and/or dietitian, and a plan developed to correct it.

3. To prevent the potential for reoccurrence the DON and/or designee educated all licensed staff on the need to strike out incorrect documentation when entered in error.

4. To monitor and maintain ongoing compliance the DON and/or designee will review recorded weights 1 time weekly for 3 months to ensure they are accurate, the MD and dietitian are aware of weight changes, and that a plan is developed to address them. Findings will be presented to facility QAPI for continued review and recommendation.

483.25(l) REQUIREMENT Dialysis:

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

Observations:

Based upon observations, clinical record review and staff interviews, it was determined that the facility failed to ensure fluid restrictions were followed for one of one dialysis resident reviewed. (Resident 16).

Findings include:

Review of Resident 16's clinical record revealed diagnoses including but not limited to end stage renal disease (ESRD- failure of kidney function to remove toxins from blood) and dementia (general loss of cognitive abilities, including memory).

Review of Resident physician's orders revealed an order for daily fluid restriction of 1500 ml daily as follows: Nursing to give 7-3 shift 240 ml; 3-11 shift 660 ml; 11-7 shift 120 ml; dietary daily 480 ml.

Review of Resident 16's Fluid Task sheet revealed Resident 16 exceeded the daily fluid restriction allotment as follows: February 11, 2025 - 420 ml; February 14, 2025- 420 ml; February 15, 2025- 540 ml; February 17, 2025 - 300 ml; March 1, 2025 - 780 ml; March 2, 2025 - 420 ml; March 5,2025-180ml; March 6, 2025-300ml.

Interview with Director of Nursing on March 7, 2025, at approximately 12:25pm confirmed the above findings.

28 Pa. Code: 211.5(f) Clinical records

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

Plan of Correction - To be completed: 04/09/2025

1. Fluid restriction order for R16 was reviewed by the MD and clarified.

2. All residents requiring fluid restrictions have the potential to be affected. On 3/25/2025 the DON and/or designee audited fluid restriction documentation to ensure the order was clear. Where necessary the order was clarified by the MD and/or dietitian.

3. To prevent the potential for reoccurrence the DON and/or designee will educate all licensed staff on fluid restrictions with emphasis on how to write the order.

4. To monitor and maintain ongoing compliance, the DON/designee will audit 2 random residents with fluid restriction orders 1 time weekly for 3 months to ensure that orders are clear. If an issue is observed it will be reviewed with the physician, new orders received, and the responsible person reeducated. Findings will be presented to facility QAPI for continued review and recommendation.

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 upon clinical record review, it was determined the facility failed to monitor for effectiveness or side effects of anti-depressant medication for one of five residents reviewed (Resident 93).

Findings include:

Review of Resident 93's diagnosis list revealed diagnoses including psychotic disorder with hallucinations, Parkinson's disease (progressive disease of the central nervous system characterized by tremors, muscle weakness and unsteady gait), persistent mood disorder and dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability.)

Review of Resident 93's physician orders revealed order and order dated December 21, 2024, for Lexapro (anti-depressant medication) 10 milligrams (mg) to be administered daily for behaviors and an order dated January 7, 2025, for Wellbutrin (anti-depressant medication) 150 mg to be administered daily.

Review of Resident 93's active care plan revealed attempts were to be made for non-pharmaceutical interventions and to monitor Resident 93's mood and behavior while receiving Lexapro and Wellbutrin.

Review of Resident 93's clinical record including Resident 93's Medication Administration Record (MAR) failed to reveal evidence that Lexapro and Wellbutrin were being monitored for effectiveness, i.e. reduction in behaviors.

Further review of Resident 93's clinical record failed to reveal evidence that Resident 93 was being monitored for side effects of Wellbutrin or Lexapro.

Interview with the Director of Nursing on March 7, 2025, at 11:07 a.m. confirmed that no monitoring for effectiveness was completed during Resident 93's use of Wellbutrin or Lexapro.

This interview further confirmed that no monitoring for side effects was completed for the use of Lexapro and Wellbutrin.

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

Plan of Correction - To be completed: 04/09/2025

1. Behavior monitoring for R93 was initiated at time of discovery.

2. All residents requiring psychotropic medications have the potential to be affected. On 3/27/2025 the DON and/or designee reviewed resident orders to ensure that behavior monitoring was present. Where necessary the order was added.

3. To prevent the potential for reoccurrence the DON and/or designee educated all licensed staff on psychotropic drugs with emphasis on ensuring a behavior monitoring order is in place at onset of utilization.

4. To monitor and maintain ongoing compliance the DON and/or designee will review 5 residents requiring psychotropic drugs 1 time a week for 3 months to ensure behavior monitoring orders are in place. If necessary, the order will be written and the responsible person immediately reeducated. Findings will be presented to facility QAPI for continued review and recommendation.

§ 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.

Observations:

Based on review of facility staffing data, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents for three of three weeks of facility staffing reviewed (weeks of September 1, 2024, December 24, 2024, and February 28, 2025).

Findings include:

Review of the weeks of September 1, 2024, December 24, 2024,and February 28, 2025, revealed the following dates on day shift did not meet the requirement of one nurse aide per 10 residents:

September 7, 2024, December 25, 2024, December 28, 2024, December 29, 2024, February 28, 2025, March 1, 2025, March 2, 2025, and March 4, 2025.

Interview with the Nursing Home Administrator on March 7, 2025, at 1:00 p.m. when the above was presented the Nursing Home Administrator (NHA) confirmed that the aide staffing ratios were not met on the above days.

Plan of Correction - To be completed: 03/31/2025

1) Staff was educated on calling off in a timely manner and following all attendance policy and procedure in regards to clocking in and out.

2) Staffing reviewed on each workday to ensure vacant nurse aide shifts are filled to meet the ratio requirements, and the hours set which have been determined by census, and the ratio requirement are accurate, and all efforts are made to replace, fill, and or meet all necessary requirements.

3) Education provided to management staff to ensure that all ratios for nursing aide staffing are adhered to in order to meet the regulated needs based on census. All processes will be reviewed with the management team in regard to utilizing the staffing call list as well as the agency platforms to acquire replacement staff if needed.

4) NHA and or designee to review staffing daily to ensure ratio requirement is met for two weeks from 3/17/25 until 3/31/25. Ongoing monthly reviews will be conducted to ensure all staffing minimums are met. All findings will be reported to the QAPI committee for continued review and revision.

§ 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 facility staffing data, it was determined that the facility failed to ensure a minimum of one licensed practical nurse per 25 residents for day shift and one licensed practical nurse per 30 residents for evening shift for two of three weeks of facility staffing reviewed (weeks of September 1, 2024, December 24, 2024).

Findings include:

Review of the weeks of September 1, 2024, December 24, 2024,and February 28, 2025, revealed the following dates on day shift did not meet the requirement of one licensed practical nurse per 25 residents:

September 7, 2024.

Review of the weeks of September 1, 2024, December 24, 2024,and February 28, 2025, revealed the following dates on evening shift did not meet the requirement of one licensed practical nurse per 30 residents:

December 25, 2024, December 28, 2024, December 29, 2024.

Interview with the Nursing Home Administrator on March 7, 2025, at 1:00 p.m. when the above was presented the Nursing Home Administrator (NHA) confirmed that the licensed practical nurse staffing ratios were not met on the above days.

Plan of Correction - To be completed: 03/31/2025

1) Staff was educated on calling off in a timely manner and following all attendance policy and procedure in regards to clocking in and out.

2) Staffing reviewed daily to ensure vacant shifts are filled to meet the ratio requirements, and the hours set which have been determined by census and the ratio requirement are accurate and all efforts are made to replace, fill, and or meet all necessary requirements.

3) Education provided to management staff to ensure that all hours, ratios, and ppd are adhered to in order to meet the regulated needs based on census. All processes will be reviewed with the management team in regard to utilizing the staffing call list as well as the agency platforms to acquire replacement staff if needed.

4) NHA and or designee to review staffing daily to ensure LPN ratio requirement is met for two weeks from 3/17/25 until 3/31/25. Ongoing monthly reviews will be conducted to ensure all staffing LPN minimum hours are met. All findings will be reported to the QAPI committee for continued review and revision.

§ 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.

Observations:

Based on review of facility staffing, it was determined that the facility failed to ensure the total number of general nursing care hours provided in each 24-hour period was a minimum of 3.20 hours per patient day (PPD) for four of twenty-one days of staffing reviewed (Weeks of September 1, 2024, December 24, 2024, January 31, 2025, and February 28, 2025).

Findings include:

Review of facility staffing revealed the following dates were below 3.2 hours PPD:

September 7, 2024, with a PPD of 3.11
December 28, 2024, with a PPD of 3.11
March 1, 2025, with a PPD of 3.17
March 4, 2025, with a PPD of 3.19

Interview with the Nursing Home Administrator on March 7, 2025, at 1:00 p.m. when the above was presented the Nursing Home Administrator (NHA) confirmed that the PPD ratios were not met on the above days.

Plan of Correction - To be completed: 03/31/2025

1) Staff was educated on calling off in a timely manner and following all attendance policy and procedure in regard to clocking in and out.

2) Staffing reviewed daily to ensure vacant shifts are filled to meet the PPD requirements which have been determined by census, and all efforts are made to replace, fill, and or meet all necessary PPD requirements.

3) Education provided to management staff to ensure that all hours, ratios, and ppd are adhered to in order to meet the regulated needs based on census. All processes will be reviewed with the management team in regard to utilizing the staffing call list as well as the agency platforms to acquire replacement staff if needed.

4) NHA and or designee to review staffing daily to ensure PPD requirement is met for two weeks from 3/17/25 until 3/31/25. Ongoing monthly reviews will be conducted to ensure all staffing minimums are met. All findings will be reported to the QAPI committee for continued review and revision.

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