Pennsylvania Department of Health
KADIMA REHABILITATION & NURSING AT LATROBE
Patient Care Inspection Results

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KADIMA REHABILITATION & NURSING AT LATROBE
Inspection Results For:

There are  242 surveys for this facility. Please select a date to view the survey results.

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KADIMA REHABILITATION & NURSING AT LATROBE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:


Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey, and a complaint survey completed on May 20, 2025, it was determined that Kadima Rehabilitation and Nursing at Latrobe 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:


483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that care plans were updated to reflect changes in residents' care needs for five of 36 residents reviewed (Residents 3, 17, 33, 58, 61).

Findings include:

The facility's policy regarding care plans, dated May 14, 2025, indicated that the resident will be reassessed at least quarterly, and the care plan will be reviewed by the interdisciplinary team.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's care needs and abilities) for Resident 3, dated February 21, 2025, indicated that the resident was cognitively intact and required assistance from staff for daily care needs. A care plan for Resident 3, dated June 14, 2024, indicated that the resident had a foley catheter (thin flexible tube inserted into the bladder to drain urine).

A nurse's note for Resident 3, dated January 22, 2025, indicated that the resident's foley catheter came out and orders were received to not re-insert the foley catheter. There was no documented evidence to indicate the care plan was updated to reflect the discontinuation of the foley catheter.

Interview with the Director of Nursing on May 20, 2025, at 1:01 p.m. confirmed that Resident 3's care plan was not updated when her foley catheter was discontinued and should have been.

A quarterly MDS assessment for Resident 17, dated February 3, 2025, revealed that the resident was understood, could understand others, and received an anticoagulant (medications that prevent blood from clotting) during the review period. A care plan for the resident, dated January 27, 2025, revealed that the resident was on anticoagulant therapy.

Physician's orders for Resident 17, dated January 12, 2025, included an order for staff to administer one five milligrams (mg) of Apixaban (a medication used to prevent and treat blood clots) two times a day. The Apixaban was discontinued on February 17, 2025. However, as of May 20, 2025, there was no documented evidence that Resident 17's care plan was revised/updated to indicate that the resident was no longer receiving anticoagulant therapy.

Interview with the Director of Nursing on May 20, 2025, at 12:50 p.m. confirmed that there was no documented evidence that Resident 17's care plan was revised/updated to indicate that the resident was no longer receiving anticoagulant therapy.

A quarterly MDS assessment for Resident 33, dated February 4, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included pneumonia (infection of the lungs). The current care plan for Resident 33 indicated that the resident was receiving an antibiotic for cellulitis (skin infection) of the left hip.

Physician's orders for Resident 33, dated March 8, 2025, included an order for the resident to receive 875-125 mg of Amoxicillin-Pot Clavulanate twice a day for a wound infection for seven days, and physician's orders, dated March 19, 2025, included orders for the resident to receive 800-160 mg of Bactrim DS twice a day for a wound infection for 10 days. However, as of May 20, 2025, there was no documented evidence that Resident 33's care plan was revised/updated to indicate that the resident was no longer receiving an antibiotic

Interview with the Director of Nursing on May 20, 2025, at 10:27 a.m. confirmed that Resident 33's care plan was not revised to indicate that he was no longer receiving an antibiotic.

A significant change MDS assessment for Resident 58, dated March 27, 2025, indicated that the resident was severely cognitively impaired, was dependent on staff for daily care needs, and had diagnoses that included pneumonia (infection of the lungs). A care plan for Resident 58, dated April 15, 2025, indicated that the resident was on an anticoagulant and that staff were to administer the medication as ordered by the physician. However, a review of the Medication Administration Record (MAR) for Resident 3, dated May 2025, revealed no documented evidence that the resident was receiving an anticoagulant medication.

Interview with the Director of Nursing on May 19, 2025, at 11:40 a.m. confirmed that Resident 58's care plan was not revised to indicate that she was not on an anticoagulant medication, and it should have been.

A significant change MDS assessment for Resident 61, dated April 13, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included pneumonia (infection of the lungs). A care plan for Resident 61, dated March 14, 2024, indicated that the resident was on an anticoagulant and that staff were to refer to the Resident's MAR for the dose and frequency of medication. However, review of the MAR for Resident 61, dated May 2025, revealed no documented evidence that the resident was receiving an anticoagulant medication.

Interview with the Director of Nursing on May 19, 2025, at 11:40 a.m. confirmed that Resident 61's care plan was not revised to indicate that she was not on an anticoagulant medication, and it should have been.

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




 Plan of Correction - To be completed: 06/24/2025

Resident # 3, 17, 33, 58, and 61's care plans were update to reflect identified changes.
The Minimum Data Set Coordinator was educated by the Director of Nursing on identified care plan changes.
Current residents' plans of care will be audited by the Director of Nursing/designee to ensure accuracy.
The Interdisciplinary Team will review the order listing report in morning clinical meeting to ensure new and discontinued orders and changes are accurately reflected in each resident's plan of care.
Licensed staff and the Minimum Data Set Coordinator were educated by the Director of Nursing/Designee on care plan updates and the requirements and guidelines related to FTAG 0657.
The Director of Nursing/Designee will complete a random weekly audit on care plans to ensure changes have been captured.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary: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.
§483.60(i) Food safety requirements.
The facility must -

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

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


Based on a review of manufacturer's instructions, observations, and staff interviews, it was determined that the facility failed to ensure that ice was stored under sanitary conditions for the ice machine next to the kitchen.

Findings include:

The manufacturer's instructions, undated, for the use of the ice machine in the main dining room, stated that the drain line must have a 1.5-inch drop per 5 feet of run and must not create traps and that the floor drain must be large enough to accommodate drainage from all drains.

Observations of the ice machine in the main dining room on May 17, 2025, at 9:17 a.m. revealed that the ice machine drain was draining into a bath basin and that the drain pipe was lying in the stagnant water in the basin. There was a small pump pumping some of the water into the nearby sink. There was no air gap between the drain pipe and the basin.

Interview with Nursing Home Administrator on May 18, 2025, at 9:52 a.m. revealed that the ice machine was removed from service until the proper drainage system with air gap could be installed.

28 Pa. Code 211.6(f) Dietary Services.

28 Pa. Code 207.4 Ice Containers and Storage.


 Plan of Correction - To be completed: 06/24/2025

The Maintenance Director locked out/tagged out the facility ice machine on 05/17/2025. Bagged ice was purchased by the facility and will be utilized until an air gap is placed on the ice machine. An air gap was placed in the ice machine.
The facility utilizes one ice machine.
The Maintenance Director was educated by the Nursing Home Administrator on FTAG 0812 regulation and guidelines.
The Nursing Home Administrator/Designee will complete a monthly audit on required air gaps in the facility.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

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


Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice, by failing to ensure that physician's orders were followed for two of 36 residents reviewed (Residents 17, 78).

Findings include:

An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 17, dated February 3, 2025, revealed that the resident was understood, could understand others, and had a diagnosis of included hypertension (high blood pressure).

Physician's orders for Resident 17, dated March 6, 2025, included an order for staff to administer one 25 milligram (mg) tablet of Metoprolol (used alone or in combination with other medications to treat high blood pressure) two times a day, and staff was to hold the medication if the systolic blood pressure (the top number of a blood pressure reading) was less than 90 millimeters of mercury (mmHg) or if the heart rate was less than 60 beats per minute.

Review of the Medication Administration Record (MARs) for Resident 17, dated April 2025, revealed that staff administered the one 25 mg tablet of Metoprolol to the resident twice a day on April 11 through 21, 2025: however, there was no documented evidence that staff obtained the resident's blood pressure and heart rate prior to the administration to determine if the medication should have been held.

A quarterly MDS assessment for Resident 78, dated February 17, 2025, revealed that the resident was understood and could understand others. A care plan for the resident, dated December 18, 2024, revealed that the resident has hypertension, and staff was to give anti-hypertensive medications and obtain blood pressure readings as ordered.

Physician's orders for Resident 78, dated March 6, 2025, included an order for staff to administer one 25 mg tablet of Metoprolol two times a day, and staff was to hold the medication if the systolic blood pressure was less than 90 mmHg or if the heart rate was less than 60 beats per minute.

Review of the MARs for Resident 78, dated April 2025, revealed that staff administered the one 25 mg tablet of Metoprolol to the resident twice a day on April 11 through 21, 2025; however, there was no documented evidence that staff obtained the resident's blood pressure and heart rate prior to the administration to determine if the medication should have been held.

Interview with the Director of Nursing on May 20, 2025, at 10:26 a.m. confirmed that there was no documented evidence that staff obtained Resident 17 and Resident 78's blood pressure and heart rate prior to the administration of the one 25 mg tablet of Metoprolol on the above dates.

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



 Plan of Correction - To be completed: 06/24/2025

Resident #17 and # 78's antihypertensive medications were reviewed by the provider with parameters previously discontinued.
The Director of Nursing/designee will audit current resident's antihypertensive medications for parameters, along with a review by the physician for the need of related parameters.
The Interdisciplinary Team will review the order listing report in morning clinical meeting to ensure antihypertensive medication parameters are reviewed for necessity and documented as applicable.
Licensed nursing staff were educated by the Director of Nursing/Designee on antihypertensive parameters and documentation including the requirements and guidelines related to FTAG 0684.
The Director of Nursing/Designee will complete a random weekly audit on antihypertensive medications for parameter documentation if applicable.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions: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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.
Observations:


Based on clinical record reviews and resident and staff interviews, it was determined that the facility failed to honor the resident's right to make informed choices and participate in his/her treatment for one of 36 residents reviewed (Resident 52).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 52, dated January 31, 2025, indicated that the resident was always understood, could always understand others, and was cognitively intact.

A nursing note for Resident 52, dated April 29, 2025, revealed that the resident was to be discharged into the care of his brother on May 9, 2025.

An interview with Resident 52 on May 17, 2025, at 10:15 a.m. revealed that the resident was looking for answers regarding his discharge plans. He stated that he thought he was supposed to go home a couple weeks ago, but that no one has talked to him to explain anything to him. He stated that his mother told him that the staff were "dragging their feet" about his discharge.

Interview with the Nursing Home Administrator on May 18, 2025, at 11:03 a.m. revealed that the Social Worker had been in touch with the resident's brother, and he had the flu and they wanted to get a ramp installed prior to his discharge. She stated that the Social Worker should have communicated this to the resident and should have charted it in his medical record as well.

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



 Plan of Correction - To be completed: 06/24/2025

The Social Services Director updated Resident # 52's progress notes to reflect discharge updates.
Resident # 52 was discharged from the facility on 05/24/2025.
The Social Services Director will complete an audit of upcoming resident discharges to ensure residents are informed and a progress note reflects as such.
The Social Service Director will initiate a weekly discharge meeting, including the Interdisciplinary Team, to ensure upcoming resident discharges are informed of discharge plans.
The Social Services Director was educated by the Nursing Home Administrator on resident discharges and guidelines and regulations related to FTAG 0552.
The Nursing Home Administrator/Designee will complete a weekly audit on the resident discharges to ensure resident are informed of discharges with corresponding progress notes.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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(b) The facility must develop and implement written policies and procedures that:

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

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

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

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

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

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

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


Based on review of policies and employee files, as well as staff interviews, it was determined that the facility failed to ensure that license checks were obtained prior to hire for one of one registered nurse reviewed (RN 1).

Findings include:

The facility's policy regarding protection from abuse, dated November 1, 2024, indicated that policies and procedures were developed to aid in preventing abuse, neglect, or mistreatment of residents, and protocols for conducting employment background checks and screening of employees.

The personnel file for Registered Nurse 1 revealed a start date of March 9, 2025, with a license check done on March 10, 2025. There was no documented evidence that a license check was obtained prior to the staff's start date of March 9, 2025.

Interview on May 19, 2025, at 12:50 p.m. with Regional Human Resources Director revealed that Registered Nurse 1's license check should have been completed prior to her start date and it was not.

28 Pa. Code 201.14(a) Responsibility of Licensee

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



 Plan of Correction - To be completed: 06/24/2025

The Regional Director of Human Resources Director and the Human Resources Assistant were educated on the need for verifying licenses for licensed professionals prior to the first day of employment.
The Regional Director of Human Resources and Human Resources Assistant audited current licensed staff to ensure licensure was validated.
The Regional Director of Human Resources/Designee will review all prospective licensed staff hires with the Nursing Home Administrator to validate licensure was verified prior to the first day of working.
The Regional Human Resources Director and Human Resources Assistant were educated by the Nursing Home Administrator on the need for verifying licenses for licensed professionals prior to the first day of employment and guidelines and regulations related to FTAG 0607.
The Regional Human Resources Director/Designee will complete a weekly audit on prospective hires to ensure licensure was validate prior to the first day of employment.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

§483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals.

§483.20(i) Certification.
§483.20(i)(1) A registered nurse must sign and certify that the assessment is completed.
§483.20(i)(2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment.

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.
Observations:


Based on a review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for five of 36 residents reviewed (Residents 17, 20, 21, 25, 61).

Findings include:

The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the intent of Section N was to record the number of days, during the seven days of the assessment period, that any type of injection, insulin, and/or select medications were received by the resident. Section N0410F1 (Antibiotic Medications) was to be coded if an antibiotic medication was taken by the resident at any time during the seven-day look-back period; Section N0415B was to be coded "yes" if the resident received an anti-anxiety medication; and Section N0415I1 (Antiplatelet Medications - medications used to reduce the risk of blood clots) was to be checked if the resident received an anti-platelet medication during the seven-day assessment period.

Physician's orders for Resident 17, dated January 12, 2025, included an order for the resident to receive 81 milligrams (mg) of aspirin daily. The resident's Medication Administration Record (MAR) for January and February 2025 revealed that the resident received aspirin daily during the seven-day look-back period. However, a quarterly MDS assessment for Resident 17, dated February 3, 2025, revealed that Section N0415I1 was coded zero (0), indicating that the resident did not receive an anti-platelet during the last seven days.

Interview with the Director of Nursing on May 20, 2025, at 12:50 p.m. confirmed that Resident 17's MDS assessment was not coded accurately.

Physician's orders for Resident 20, dated July 10, 2024, included an order for the resident to receive Clobazam (an anti-anxiety medication) daily for seizures. The resident's Medication Administration Record (MAR) for May 2025 revealed that the resident received Clobazam daily. However, a quarterly MDS assessment for Resident 20, dated May 12, 2025, revealed that Section N0415B indicated that the resident did not receive an anti-anxiety medication during the assessment period.

Interview with Director of Nursing on May 20, 2025, at 1:18 p.m. confirmed that Resident 20's MDS assessment was not coded accurately.

Physician's orders for Resident 21, dated September 11, 2020, included an order for the resident to receive 81 mg of aspirin daily. The resident's MAR, dated March 2025, revealed that the resident received aspirin daily during the seven-day look-back period. However, an annual MDS assessment for Resident 21, dated March 14, 2025, revealed that Section N0415I1 was coded zero (0), indicating that the resident did not receive an anti-platelet during the last seven days.

Interview with the Director of Nursing on May 20, 2025, at 12:20 p.m. confirmed that Resident 21's MDS assessment was not coded accurately.

Physician's orders for Resident 25, dated February 6, 2025, included an order for the resident to have the first finger on his left hand cleansed with normal saline solution (salt water solution) and triple antibiotic ointment applied to the wound bed and covered with a dry dressing every evening shift. The resident's Treatment Administration Records (TAR's) for February 2025 revealed that the resident received triple antibiotic ointment every evening from February 6 through 28, 2025. However, a quarterly MDS assessment for Resident 25, dated February 26, 2025, revealed that Section N0410F1 was not checked, indicating that the resident did not receive any antibiotic medications during the seven-day look-back period.

Interview with the Nursing Home Administrator on May 20, 2025, at 10:27 a.m. confirmed that Resident 25's MDS assessment was not coded accurately.

Physician's orders for Resident 61, dated December 1, 2023, and discontinued April 9, 2025, included an order for the resident to receive 81 mg of aspirin daily. The resident's MAR, dated April 2025, revealed that the resident received aspirin on April 7, which was within the seven-day look-back period. However, a significant change MDS assessment for Resident 61, dated April 13, 2025, revealed that Section N0415I1 was coded zero (0), indicating that the resident did not receive an anti-platelet during the last seven days.

Interview with the Director of Nursing on May 20, 2025, at 12:20 p.m. confirmed that Resident 61's MDS assessment was not coded accurately.

28 Pa. Code 211.5(f) Clinical Records.



 Plan of Correction - To be completed: 06/24/2025

The facility corrected R17, R20, R21, R25 and R61 assessments to accurately reflect medications received.
MDS nurse will audit all in-house residents that are currently on aspirin, clobazam and triple antibiotic ointment to ensure N0415B, N0415F and N0415I is coded correctly on the most recent Minimum Data Set.
Minimum Data Set Nurse will be reeducated by Regional Minimum Data Set Nurse on accurate coding of section N0415 High risk drug classes
Regional Minimum Data Set Nurse/designee will audit 5 assessments weekly x 4 and then monthly x 2 to ensure 100% accuracy of N0415B, N0415F and N0415I. Outcomes will be reported by MDS nurse at Quality Assurance for review and recommendations

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

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


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to complete safety assessments for one of 36 residents reviewed who used siderails (Resident 3) and two of 36 residents reviewed (Residents 9, 25) who used an air mattress.

Findings include:

A facility policy for siderails dated May 14, 2025, indicated that an assessment will be made to determine the resident's symptoms or reason for using siderails. The use of siderails will be evaluated in terms of risk and benefit for each individual resident.

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated February 21, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included infection of a right knee prosthesis (artificial replacement).

A side rail/assist bar evaluation/assessment for Resident 3, dated March 21, 2025, indicated that the resident was being assessed for an assist bar. Section D was not completed to identify if side rails/assist bars were indicated or not indicated. However, observations of Resident 3 on May 17, 2025, at 10:30 a.m., on May 18, 2025, at 10:17 a.m., and on May 18, 2025, at 9:17 a.m. revealed that the resident was lying in bed with bilateral upper siderails up on her bed.

Interview with the Director of Nursing on May 20, 2025, at 1:20 p.m. confirmed that the last two siderail assessments for Resident 3 were not fully completed to identify whether siderails were indicated or not.

A quarterly MDS assessment for Resident 9, dated February 2, 2025, revealed that the resident was cognitively intact, was dependent on staff for personal care needs, and had diagnoses that included chronic deep vein thrombosis (blood clot in a deep vein that has lasted for at least a month). Physician's orders for Resident 9, dated February 21, 2025, indicated that the resident was to have an air mattress that was checked for function every shift. A care plan for Resident 9, dated May 24, 2025, indicated that the resident had potential for impaired skin integrity and that he should have an air mattress that was checked for function every shift.

Observations of Resident 9 on May 17, 2025, at 10:40 a.m. revealed that the resident was lying in bed, and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed.

A quarterly MDS assessment for Resident 25, dated February 26, 2025, revealed that the resident was cognitively impaired, was dependent on staff for personal care needs, was at risk for developing pressure sores, and had diagnoses that included cerebral palsy (a group of lifelong conditions that affect movement and coordination, caused by brain damage that occurs before, during, or shortly after birth). Physician's orders for Resident 25, dated May 6, 2025, indicated that the resident was to have an air mattress for every shift. A care plan for Resident 25, dated May 8, 2025, indicated that the resident had potential for impaired skin integrity and should have an air mattress every shift.

Observations of Resident 25 on May 18, 2025, at 1:54 p.m. and May 19, 2025, at 1:23 p.m. revealed that the resident was lying in bed, and the bed was equipped with an air mattress; however, there was no documented evidence that the use of an air mattress was assessed for potential safety hazards prior to being placed on the resident's bed.

Interview with the Director of Nursing on May 20, 2025, at 1:38 p.m. revealed that the facility did not have air mattress safety assessments completed on residents who used air mattresses at the time of the survey.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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

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



 Plan of Correction - To be completed: 06/24/2025

Resident # 3 had a siderail assessment completed. Resident # 9 and 25 had an air mattress safety assessment completed.
The Director of Nursing/ Designee completed an in-house audit of facility side rails to validate resident utilizing enabler bars have a current assessment in place.
The Director of Nursing/Designee completed an air mattress safety assessment on current residents utilizing air mattresses.
The Interdisciplinary Team will review the order listing report in morning clinical meeting to ensure to any newly ordered enabler bars and air mattresses have a safety assessment in place.
The Director of Nursing/Designee educated licensed nursing staff and facility maintenance staff on the need for an enabler assessment and air mattress safety assessment and requirements related to FTAG 0689.
The Director of Nursing/Designee will complete a weekly audit on side rail assessments and air mattress safety risk assessments to ensure the assessments are in place and up to date.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

483.25(e)(1)-(3) REQUIREMENT Bowel/Bladder Incontinence, Catheter, UTI: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(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.

§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.

§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
Observations:


Based on clinical record reviews and observations, as well as staff interviews, it was determined that the facility failed to ensure urinary output was monitored for two of 36 residents reviewed (Residents 33, 78) who had an indwelling urinary catheter.

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of the resident's abilities and care needs) for Resident 33, dated February 4, 2025, revealed that the resident was cognitively impaired and had an indwelling urinary catheter (a flexible tube inserted and held in the bladder to drain urine). A care plan for Resident 33, dated November 1, 2024, revealed that the resident had an indwelling catheter related to a diagnosis of benign prostatic hyperplasia (a condition where the prostate gland becomes enlarged, which can cause urinary problems) and staff was to measure the urinary output as ordered.

Physician's orders for Resident 33, dated February 19, 2025, included an order for staff to document the indwelling urinary catheter output every shift.

Observation of Resident 33 on May 19, 2025, at 8:31 a.m. revealed that the resident had an indwelling urinary catheter.

Review of Resident 33's clinical record including the Medication Administration Records (MARs), Treatment Administration Records (TARs), and nurse aide documentation revealed no documented evidence that the resident's indwelling urinary catheter output was documented during the day shift on April 6; during the evening shift on March 17, April 21, and May 11 and 14; and during the night shift on March 12, 26, 29, and 31, April 3, 5, and 15, and May 14, 2025.

Interview with the Director of Nursing on May 20, 2025, at 1059: a.m. confirmed that there was no documented evidence that Resident 33's indwelling urinary catheter output was documented on the dates and times listed above.

A quarterly MDS assessment for Resident 78, dated February 17, 2025, revealed that the resident was understood, could understand others, and had an indwelling urinary catheter. A care plan for the resident, dated November 26, 2024, revealed that the resident had an indwelling catheter related to a diagnosis of a neurogenic bladder (a condition where the nerves that control the bladder do not function properly, leading to difficulties with urination) and staff was to measure the urinary output as ordered.

Physician's orders for Resident 78, dated February 19, 2025, included an order for staff to document the indwelling urinary catheter output every shift.

Review of Resident 78's clinical record including the MARs, TARs, and nurse aide documentation revealed no documented evidence that the resident's indwelling urinary catheter output was documented during the evening shift on April 16 and 24, 2025, and during the night shift on May 5, 2025.

Interview with the Director of Nursing on May 20, 2025, at 11:00 a.m. confirmed that there was no documented evidence that Resident 78's indwelling urinary catheter output was documented during the evening shift on April 16 and 24, 2025, and during the night shift on May 5, 2025.

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


 Plan of Correction - To be completed: 06/24/2025

Resident # 33 and # 78 urinary catheter outputs are being recorded by nursing staff every shift.
The Director of Nursing/Designee will review current residents with catheters to ensure urinary output is being documented each shift.
The Interdisciplinary Team will review the facility documentation in morning clinical meeting to ensure ordered urinary outputs are being captured.
The Director of Nursing/ Designee will educate current nursing staff on output documentation and the requirements and guideline related to FTAG 0690.
The Director of Nursing/Designee will complete a weekly audit resident with ordered urinary output for ordered documentation.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

483.35(i)(1)-(4) REQUIREMENT Posted Nurse Staffing Information: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.
§483.35(i) Nurse Staffing Information.
§483.35(i)(1) Data requirements. The facility must post the following information on a daily basis:

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

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

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

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


Based on observations and staff interviews, it was determined that the facility failed to ensure that the posting of their nurse staffing was current.

Findings include:

Observations on May 17, 2025, at 9:00 a.m. revealed that the nurse staffing information that was posted at the main entrance of the facility was dated May 15, 2025, and was not current.

Interview with the Nursing Home Administrator on May 17, 2025, at 9:55 a.m. confirmed that the nurse staffing information that was posted was dated May 15, 2025, and was not the current staffing information as required.

28 Pa. Code 201.14(a) Responsibility of Licensee.



 Plan of Correction - To be completed: 06/24/2025

The nurse staffing information for 05/17/2025 was posted at the facility entrance by the current scheduler.
A new scheduler was hired and is currently orienting. Both schedulers were educated by the NHA on 05/17/2025 on posted nurse staffing information and the regulation and guidelines relates to FTAG 0732.
Current facility registered nurses were also educated by the Nursing Home Administrator/Designee on posted nurse staffing information and the regulation and guidelines relates to FTAG 0732 to ensure the information is posted when the scheduler is not in the facility.
The Nursing Home Administrator/Designee will complete a random weekly audit to ensure the nurse staffing information is posted as required.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

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


Based on review of policies, as well as observations and staff interviews, it was determined that the facility failed to ensure that a controlled drug was properly stored in one of two medication rooms reviewed (East Side Medication Room).

Findings include:

The facility's policy regarding storing controlled medications, dated November 1, 2024, indicated that Ativan (a controlled substance used to treat anxiety) was to be under double-lock security. The access key to controlled medications is not the same key that allows access to other medications.

Observations of the East Side medication room on May 17, 2025, at 12:10 p.m. revealed one opened vial of Ativan that was not stored in a separately locked, permanently affixed container.

Interview with Licensed Practical Nurse 2 on May 17, 2025, at 12:10 p.m. confirmed that there was no separately locked, permanently affixed container for the Ativan, and that it was just stored in the medication refrigerator with other non-controlled medications.

Interview with Director of Nursing on May 18, 2025, at 9:58 a.m. confirmed that the vial of Ativan should have been in a separately locked, permanently affixed container and it was not.

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


 Plan of Correction - To be completed: 06/24/2025

The narcotic noted in the East Wing refrigerator was destroyed by two Registered Nurses on 05/17/2025 as the resident just ceased to breathe. There were no additional narcotics in the East Wing refrigerator per the Director of Nursing. The Maintenance Director installed a lock box inside the East Wing refrigerator to ensure refrigerated narcotics were under a double lock system.
The Director of Nursing Completed an in-house audit of facility medication refrigerators to ensure narcotics requiring refrigeration were under a double lock.
Current facility licensed staff was educated by the Director of Nursing/Designee on a double lock requirement for a permanently affixed, locked refrigerator container and FTAG 0761 regulation and guidelines.
The Director of Nursing/Designee will complete a random audit ensuring refrigerated narcotics are under a double lock to include a permanently affixed, locked refrigerator container.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.


483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:


Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to maintain clinical records that were accurately documented for two of three residents reviewed (Residents 2, 3).

Findings include:

A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 32, dated May 2, 2025, revealed that the resident was confused.

A nursing note for Resident 32, dated May 30, 2025, revealed that the resident was missing a part of her front tooth and a piece of the tooth next to it. She was crying, asking for a dentist, and stating that her tooth hurt.

There was no indication in the Resident 32's clinical record that her pain was assessed by the nurse or that the resident was referred to the dentist.

Interview with the Director of Nursing on May 20, 2025, at 1:02 p.m. revealed that the resident did see the dentist on March 31, 2025, and she provided his consult report. She stated that it should have been a part of Resident 32's clinical record.

A quarterly MDS assessments for Resident 38, dated February 7, 2025, revealed that the resident was cognitively intact and had diagnoses that included paranoid schizophrenia with outbursts.

Psychiatric note for Resident 38, dated March 19, 2025, revealed that the resident was paranoid, delusional, and required another psychiatric visit in two to eight weeks, depending on her need.

Observations of Resident 38, dated May 17, 2025, revealed that the resident was screaming loudly and talking to herself in different voices, and interacting with invisible things/people.

There was no indication that the psychiatrist was made aware of Resident 38's continued hallucinations and paranoia, or that the psychiatrist saw her again since March 19, 2025.

Interview with the Nursing Home Administrator on May 20, 2025, at 9:51 a.m. revealed that Resident 38 was seen by psychiatric services on April 23, 2025, and again on May 13, 2025; however, there was nothing in the resident's medical record to indicate that she had been seen and there should have been.

A quarterly MDS assessment for Resident 52, dated January 31, 2025, indicated that the resident was always understood, could always understand others, and was cognitively intact.

A nursing note for Resident 52, dated April 29, 2025, revealed that the resident was to be discharged into the care of his brother on May 9, 2025.

An interview with Resident 52 on May 17, 2025, at 10:15 a.m. revealed that the resident was looking for answers regarding his discharge plans. He stated that he thought he was supposed to go home a couple weeks ago, but that no one has talked to him to explain anything to him. He stated that his mother told him that the staff were "dragging their feet" about his discharge.

Interview with the Nursing Home Administrator on May 18, 2025, at 11:03 a.m. revealed that the Social Worker had been in touch with the resident's brother and should have charted it in Resident 52's clinical record.

28 Pa. Code 211.5(f) Clinical Records.



 Plan of Correction - To be completed: 06/24/2025

Resident # 32 had a pain assessment completed along with the 3/31/2025 dental consult uploaded to the resident's electronic medical record. Resident # 38 was seen by the psychiatrist on 05/19/2025 and the consult was uploaded to the resident's medical record. Resident # 52's mother is not living. The Social Services Director completed a late entry progress note on the resident regarding his current discharge plan.
The Social Services Director/Designee completed an audit on current residents to ensure those requiring dental, psychiatry, and discharge services have a current consult/discharge plan progress note in place.
The Social Servies Director and Medical Records Coordinator were educated by the Nursing Home Administrator on uploading dental and psychiatry notes and completing a discharge plan update progress note on residents timely in the electronic medical records system.
The Social Services Director/Designee will complete a weekly audit on dental psychiatry consults and planned discharged to ensure documents are noted in the residents' electronic medical record system timely.
The results of the audits will be reviewed at the monthly Quality Assurance Meeting for Interdisciplinary Team review and additional follow-up as needed.

483.75(c)(1)-(4)d)(1)(2)(e)(1)-(3)(g)(2)(ii)(iii) REQUIREMENT QAPI/QAA Improvement Activities: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.
§483.75(c) Program feedback, data systems and monitoring.
A facility must establish and implement written policies and procedures for feedback, data collections systems, and monitoring, including adverse event monitoring. The policies and procedures must include, at a minimum, the following:

§483.75(c)(1) Facility maintenance of effective systems to obtain and use of feedback and input from direct care staff, other staff, residents, and resident representatives, including how such information will be used to identify problems that are high risk, high volume, or problem-prone, and opportunities for improvement.

§483.75(c)(2) Facility maintenance of effective systems to identify, collect, and use data and information from all departments, including but not limited to the facility assessment required at §483.71 and including how such information will be used to develop and monitor performance indicators.

§483.75(c)(3) Facility development, monitoring, and evaluation of performance indicators, including the methodology and frequency for such development, monitoring, and evaluation.

§483.75(c)(4) Facility adverse event monitoring, including the methods by which the facility will systematically identify, report, track, investigate, analyze and use data and information relating to adverse events in the facility, including how the facility will use the data to develop activities to prevent adverse events.

§483.75(d) Program systematic analysis and systemic action.

§483.75(d)(1) The facility must take actions aimed at performance improvement and, after implementing those actions, measure its success, and track performance to ensure that improvements are realized and sustained.

§483.75(d)(2) The facility will develop and implement policies addressing:
(i) How they will use a systematic approach to determine underlying causes of problems impacting larger systems;
(ii) How they will develop corrective actions that will be designed to effect change at the systems level to prevent quality of care, quality of life, or safety problems; and
(iii) How the facility will monitor the effectiveness of its performance improvement activities to ensure that improvements are sustained.

§483.75(e) Program activities.

§483.75(e)(1) The facility must set priorities for its performance improvement activities that focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence, and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care.

§483.75(e)(2) Performance improvement activities must track medical errors and adverse resident events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the facility.

§483.75(e)(3) As part of their performance improvement activities, the facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the facility must reflect the scope and complexity of the facility's services and available resources, as reflected in the facility assessment required at §483.71. Improvement projects must include at least annually a project that focuses on high risk or problem-prone areas identified through the data collection and analysis described in paragraphs (c) and (d) of this section.

§483.75(g) Quality assessment and assurance.

§483.75(g)(2) The quality assessment and assurance committee reports to the facility's governing body, or designated person(s) functioning as a governing body regarding its activities, including implementation of the QAPI program required under paragraphs (a) through (e) of this section. The committee must:

(ii) Develop and implement appropriate plans of action to correct identified quality deficiencies;
(iii) Regularly review and analyze data, including data collected under the QAPI program and data resulting from drug regimen reviews, and act on available data to make improvements.
Observations:


Based on review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.

Findings include:

The facility's deficiencies and plans of corrections for an annual survey ending December 4, 2024, and a complaint survey ending January 6, 2025, revealed that the facility developed a plan of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending May 20, 2025, identified a repeated deficiency related to pharmaceutical services/accountability of narcotics.

The facility's plan of correction for a deficiency regarding inaccurate MDS assessments, cited during the survey ending December 4, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F641, revealed that the facility's QAPI committee failed to successfully implement their plan regarding completing accurate MDS assessments.

The facility's plan of correction for a deficiency regarding care plan timing and revision, cited during the survey ending December 4, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F657, revealed that the facility's QAPI committee failed to successfully implement their plan regarding care plan timing and revision.

The facility's plan of correction for a deficiency regarding quality of care, cited during the survey ending December 4, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F684, revealed that the facility's QAPI committee failed to successfully implement their plan regarding quality of care.

The facility's plan of correction for a deficiency regarding safety/accident hazards, cited during the surveys ending December 4, 2024, and January 6, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F689, revealed that the facility's QAPI committee failed to successfully implement their plan regarding safety/accident hazards.

The facility's plan of correction for a deficiency regarding medication storage, cited during the survey ending December 4, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F761, revealed that the facility's QAPI committee failed to successfully implement their plan regarding medication storage.

The facility's plan of correction for a deficiency regarding complete and accurate medical records, cited during the survey ending December 4, 2024, revealed that the facility would complete audits and report the results of the audits to the QAPI committee for review. The results of the current survey, cited under F842, revealed that the facility's QAPI committee failed to successfully implement their plan regarding complete and accurate medical records.

Refer to F641, F657, F684, F689, F761, F842.

28 Pa. Code 201.14(a) Responsibility of Licensee.

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





 Plan of Correction - To be completed: 06/24/2025

A new administrative team has been put in place since previous surveys and updated plans of correction were developed for FTAGS 641, 657, 684, 689, 761, and 842 identified in the current survey.
The current plan of correction will be reviewed and entered into the Quality Assurance Process by the Interdisciplinary Team.
The Interdisciplinary Team was educated by the Nursing Home Administration on the Quality Assurance Process and regulations and guidelines related to FTAG 0867.
Identified repeat deficiency audits will be completely randomly as noted in the current plan of correction and will continue without a noted stop date until full compliance is achieved and maintained as reviewed by the Interdisciplinary Team at the monthly Quality Assurance Meeting.



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