Pennsylvania Department of Health
 FOREST PARK NURSING AND REHABILITATION
Patient Care Inspection Results

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FOREST PARK NURSING AND REHABILITATION
Inspection Results For:

There are  203 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
FOREST PARK NURSING AND REHABILITATION - 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 completed on March 6, 2025, it was determined that Forest Park Nursing and Rehabilitation 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:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on facility policy review, observations, and staff interviews, it was determined that the facility failed to promote care for residents in a manner and environment that enhances each resident's dignity for six of 23 Residents reviewed (Residents 6, 7, 34, 42, 57, and 68).

Findings Include:

Review of facility policy, titled "Dignity," with a last review date of February 3, 2025, revealed, in part, "5. When assisting with care, residents are supported in exercising their rights. For example, residents are e. provided with a dignified dining experience; 10. Staff protect confidential clinical information. Examples include the following: b. Signs indicating the resident's clinical status or care needs are not openly posted in the resident's room unless specifically requested by the resident or family member. Discreet posting of important clinical information for safety reasons is permissible (e.g., taped to the inside of the closet door); and 12. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example: a. helping the resident to keep urinary catheter bags covered."

Observation of Resident 7 on March 3, 2025, at 11:06 AM, revealed that Resident 7 was seated in her chair and Employee 2 was standing over Resident 7, assisting her with her lunch.

Observation of Resident 34 on March 3, 2025, at 11:12 AM, revealed that Resident 34 was laying in his bed, which was in the low position to the floor, and Employee 3 was standing at the bedside, assisting him with his lunch.

Observation of Resident 6 on March 4, 2025, at 11:25 AM, revealed that Resident 6 was seated in her chair and Employee 1 was standing over Resident 6, assisting her with her lunch.

Observation of Resident 7 on March 4, 2025, at 11:40 AM, revealed that Resident 7 was seated in her chair and Employee 1 was standing over Resident 7, assisting her with her lunch.

During a staff interview with Employee 1 on March 4, 2025, at 1:35 PM, Employee 1 indicated that if she is assisting a resident in bed with their meal, she usually brings the bed up to her height to make eye contact with the resident. She further indicated that if she was assisting a resident seated in their chair with their meal, she would sit in a chair if one was available.

During a staff interview with the Nursing Home Administrator (NHA) on March 5, 2025, at 10:05 AM, the NHA confirmed that she would expect staff to be at eye-level contact with a resident when assisting them with their meals.

Observations of Resident 42's room on March 3, 2025, at 10:29 AM, and on March 4, 2025, at 10:41 AM, revealed a typed sign hanging above the head of her bed that said, "Keep head of bed elevated when on tube feeding."

Observations of Resident 57's room on March 3, 2025, at 11:00 AM, and March 4, 2025, at 10:39 AM, revealed a typed sign hanging above the head of her bed that said, "Please do not leave wipes at bedside."

During a staff interview with the NHA on March 5, 2025, at 10:58 AM, the NHA indicated that it was not a good practice to have the signs posted like those observed for public view.

Observations of Resident 68 on March 3, 2025, at 10:32 AM, and 12:52 PM, and on March 4, 2025, at 9:18 AM and 11:40 AM, all revealed that Resident 68's urinary catheter drainage bag with urine noted in the bag was visible from the hallway.

During an interview with the NHA on March 5, 2025, at 12:20 PM, the NHA indicated that she would expect Resident 68's urinary catheter bag to have a dignity cover in place to hide it from public view.

28 Pa Code 201.29(a) Resident rights
28 Pa Code 211.11(d)(1)(2) Nursing services



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

1. Facility is unable to retroactively correct deficiencies for residents # 7, 34, 6, 7. Signs were removed from resident walls for resident # 42 and 57. Catheter bag was changed to one with privacy cover for resident #68.
2. Facility will audit current residents with catheters to ensure foley bags are placed in dignity bag or one with built-in privacy cover. Facility will audit current resident rooms to ensure there are no signs openly posted in resident room that indicates clinical status or care needs unless placed by resident or resident representative.
3. DON/Designee will educate nursing staff on ensuring they are sitting at eye level with resident when assisting or feeding meals. Education will include need for residents with catheters to have dignity bags or bags with built-in privacy covers. Nursing staff will also be educated on not openly posting signs with clinical or care information in resident room unless placed by resident or resident representative. Then this must be care planned.
4. Facility will audit 10 residents weekly for 1 month then monthly for 2 months to ensure that if they require assistance with feeding staff are sitting at eye level with them, if they have catheter, urine bags have built-in privacy covers or are in dignity bag and that they have no openly posted clinical status or care need information on their walls. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.

483.80(a)(3) REQUIREMENT Antibiotic Stewardship Program: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.
§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.
Observations:

Based on facility policy review and staff interview, it was determined that the facility failed to establish and implement an antibiotic stewardship program to monitor the use of antibiotics.

Findings include:

Review of the facility's policy, titled "Antibiotic Stewardship," last revised December 2016, revealed the policy statement was, "Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program." The policy's interpretation and implementation included, "The purpose of our antibiotic stewardship program is to monitor the use of antibiotics in [the] residents."

As of March 6, 2025, at 11:45 AM, the facility was unable to provide evidence that antibiotic stewardship was implemented via providing documentation including, but not limited to, tracking antibiotics used, duration of use, and monitoring culture and sensitivity of identified organisms to ensure prescribed antibiotic effectiveness.

During a staff interview on March 6, 2025, at approximately 11:45 AM, Nursing Home Administrator revealed it was the facility's expectation that monitoring antibiotic use via an antibiotic stewardship program should be in place.

28 Pa code 211.12(d)(1)(3)(5) Nursing services


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

1- Director of Nursing in collaboration with the facility's Infection Preventionist have initiated an Antibiotic Stewardship and surveillance program with a review of all current residents on antibiotics.
2- Infection Preventionist/designee will ensure all elements of the Antibiotic stewardship and surveillance program are in place in accordance with Ftag 881 including antibiotic use monitoring.
3- Nursing Home Administrator/designee will educate the Director of Nursing and the Infection Preventionist on Ftag 881 and the importance of establishing and maintaining an effective Antibiotic Stewardship and surveillance program including antibiotic use monitoring.
4- Infection Preventionist/designee will audit the facility's antibiotic stewardship program to ensure all requirements are met in accordance with Ftag 881 including infection tracking, surveillance, reporting and antibiotic monitoring. These audits will be conducted weekly for 4 weeks and monthly thereafter. These audits will be presented to the Quality Assurance Performance Improvement Committee for recommendations.

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 facility policy review, observations, and staff interviews, it was determined that the facility failed to store food items in accordance with professional standards for food service safety in the main kitchen and three of three nourishment areas.

Findings include:

Review of facility policy, titled "Food Receiving and Storage", last revised October 2023, read, in part, "Food shall be received and stored in a manner that complies with safe food handling practices. Dry foods that are stored in bins will be removed from original packaging, labeled and dated ('use by' date). All food items to be kept at 41 degrees Fahrenheit must be placed in the refrigerator located at the nurses station and labeled with a 'use by' date."

Observation of the dry storage area on March 3, 2025, at 9:38 AM, revealed one bag of egg noodles open without an open date or use by date once opened; one bag of spiral pasta open without an open date or use by date once opened; 10 boxes of fudge round cookies not dated; and one box of potatoes that were all covered with sprouts and appeared to be old.

Interview with Employee 8 (Foodservice Director) on March 3, 2025, at 9:40 AM, revealed she preferred to store potatoes in the walk-in refrigerator to preserve their freshness, and that box of potatoes should be thrown out.

Observation in the Laurel Lane pantry area refrigerator on March 3, 2025, at 9:50 AM, revealed one honey thickened cranberry juice and one nectar thickened cranberry juice open without an open date.

Further observation of the Laurel Lane pantry area on March 3, 2025, at 9:52 AM, revealed a bin containing individually labeled snacks without dates, to indicate when the snacks expire.

Interview with Employee 8 on March 3, 2025, at 9:54 AM, revealed the snack bins should be labeled when they are replenished to indicate when the snacks will expire; and that juices should be labeled when opened, as they have guidelines on the containers to be discarded at either 7 or 10 days once opened.

Observation in the Chapel Wood pantry area refrigerator on March 3, 2025, at 9:55 AM, revealed one honey thickened orange juice; one honey thickened apple juice; and one carton of fortified nutritional drink, all open without an open date.

Further observation of the Chapel Wood pantry area on March 3, 2025, at 9:56 AM, revealed a bin containing individually labeled snacks without dates.

Observation in the Evergreen/Stepping Stone pantry area refrigerator on March 3, 2025, at 9:58 AM, revealed one honey thickened apple juice and two cartons of fortified nutritional drinks, all open without an open date.

Further observation of the Chapel Wood pantry area on March 3, 2025, at 9:59 AM, revealed a bin containing individually labeled snacks without dates.

Interview with Employee 8 on March 3, 2025, at 10:04 AM, the surveyor revealed the concern with the dry storage area of the kitchen as well as the three pantries. Employee 8 revealed she is working with the staff on proper food storage, including labeling and dating.

Interview with the Nursing Home Administrator on March 4, 2025, at 1:07 PM, revealed it was the facility's expectation that food and beverages are labeled and dated per facility policy and in accordance with professional standards.

28 Pa. Code 201.14(a) Responsibility of licensee



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

1-Food service director completed inspection and audit of dry storage area, Laurel lane pantry area refrigerator and pantry and Chapelwood pantry area refrigerator and pantry and discarded all open food items, juices and snacks that were not labeled and dated. Discarded all food items that were not in good condition for use or consumption such as sprouted potatoes. Ensured all food stored were appropriately dated, covered and in good condition for consumption or discarded if they were not.
2- Food service director will conduct a facility wide audit of all pantries and refrigerators to ensure all food items and juices are appropriately labeled, dated and covered and food items are in good condition for consumption.
3-Food service director/designee will educate dietary staff members on Ftag 812 and the importance of ensuring all food items and drinks in pantries and refrigerators that are opened are appropriately labeled, dated and covered and all food items are in good condition for consumption or discarded when they are not.
4-Food service director/designee will conduct a random sample audit of two pantries and two refrigerators to ensure all food items and drinks in pantries and refrigerators that are opened are appropriately labeled, dated and covered and all food items are in good condition for consumption or discarded when they are not. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

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

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

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

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

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

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

Based on clinical record reviews and staff interviews, it was determined that the facility failed to adequately monitor possible side effects and target behaviors for two of five residents reviewed for unnecessary psychotropic medications (Residents 68 and 80).

Findings include:

Review of Resident 68's clinical record revealed diagnoses that included depression, anxiety, and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply).

Review of Resident 68's physician orders revealed an order for lorazepam tablet 0.5 milligrams give one tablet via PEG (percutaneous endoscopic gastrostomy-a flexible feeding tube placed through the abdominal wall and into the stomach which allows nutrition to be placed directly into the stomach) tube every 6 hours as needed for anxiety for 14 days, dated February 20, 2025.

Review of Resident 68's Medication Administration Records (MARs) for February 2025 and March 2025 revealed that he had received four doses of his lorazepam: February 21, 2025, at 10:54 PM; March 3, 2025, at 11:53 AM and 9:21 PM; and March 6, 2025, at 1:14 AM.

Further review of Resident 68's MARs for February 2025 and March 2025, as well as his clinical record progress notes, revealed that there were no non-pharmacological interventions documented as being attempted prior to the lorazepam administration February 21, at 10:54 PM; March 3, at 11:53 AM; or March 6, at 1:14 AM. Further review failed to reveal any identified targeted behaviors, behavior monitoring, or side effect monitoring for the use of the lorazepam.

During a staff interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on March 6, 2025, at 12:02 PM, the DON confirmed that staff should have been documenting non-pharmacological interventions that were attempted prior to the administration of the lorazepam to Resident 68. She indicated that the order was entered incorrectly and did not allow supplemental documentation of non-pharmacological interventions to be documented on the MAR. The DON also confirmed that behaviors and medication side effects should have been monitored and documented.

Review of Resident 80's clinical record revealed diagnoses that include major depressive disorder (persistent low mood that significantly interferes with daily life) and dementia (a chronic disorder of the mental processes caused by brain disease and marked by memory disorders, personality changes, and impaired reasoning).

Review of Resident 80's physician orders revealed orders for Seroquel (antipsychotic medication) for dementia, buspirone for anxiety disorder, and mirtazapine for depression. Resident 80 also had orders for side effect monitoring every shift for antipsychotic use, antidepressant use, antianxiety medication use, and behavior monitoring every shift.

Review of Resident 80's medication administration record revealed no side effect monitoring documentation and no behavior monitoring documentation for the following dates and shifts:
day shift - January 28, 2025; February 2, 14, 15, and 28, 2025; and March 1 and 2, 2025;
evening shift - January 27, 28, 30, and 31, 2025, February 1, 2, 8, 14, 15, 22, 24, and 28, 2025; and March 1, 2, and 3, 2025;
night shift - January 28 and 29, 2025; and February 2, 6, 8, 14, 16, 19, and 26, 2025.

During an interview with the NHA and DON on March 5, 2025 at 12:13 PM, it was revealed the facility had no addition information regarding the missing documentation. The DON stated it was the expectation of the facility that side effect and behavior monitoring be done as ordered.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services



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

1-Unable to retroactively document non-pharmacological interventions and identified targeted behaviors prior to the administration of PRN anxiolytic on February 21st, March 3rd or March 6th for resident 68. Medication orders for any PRN psychoactive medications has been updated to ensure it allows for supplemental documentation of non-pharmacological interventions prior to the administration of PRN psychoactive medications as well as any identified side effects. For resident 80 unable to retroactively document behavior monitoring for day shift - January 28, 2025; February 2, 14, 15, and 28, 2025; and March 1 and 2, 2025; evening shift - January 27, 28, 30, and 31, 2025, February 1, 2, 8, 14, 15, 22, 24, and 28, 2025; and March 1, 2, and 3, 2025; night shift - January 28 and 29, 2025; and February 2, 6, 8, 14, 16, 19, and 26, 2025. Medication administration record for PRN psychoactive medication is set up with supplemental documentation that includes monitoring of targeted behavior, use of non-pharmacological interventions prior to medication administration and monitoring for side effects.
2-Director of Nursing/designee will conduct a facility wide audit of current residents with orders for psychoactive medications to ensure supplemental documentation is added as a requirement to ensure there is appropriate monitoring of possible side effects, non-pharmacological interventions attempted prior to the administration and the effectiveness of those interventions.
3-Director of Nursing/designee will educate facility licensed nurses on Ftag 758 and the importance of ensuring psychoactive medications include supplemental documentation with targeted behavior, non-pharmacological intervention attempted prior to the administration of medication and monitoring for side effects.
4-Director of Nursing/designee will conduct a random sample audit of 5 residents that have orders for PRN (as needed) and/or routine psychoactive medications to ensure there is supplemental documentation to reflect targeted behavior, non-pharmacological intervention attempted prior to the administration and its effectiveness as well as any side effects from the medications. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(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 on clinical record review and staff interviews, it was determined that the facility failed to monitor the resident's nutritional status for one of seven residents reviewed for nutrition (Resident 72).

Findings include:

Review of Resident 72's clinical record revealed diagnoses that included hypotension (low blood pressure) and atrial fibrillation (an irregular heartbeat).

Review of Resident 72's clinical record revealed a full nutrition assessment/weight change completed by the dietitian on September 13, 2024, at 10:16 PM, which read, in part, that Resident 72 triggers for significant undesired weight loss of 25% in one month and will order weekly weights for four weeks for weight monitoring. Will monitor weight trends.

Review of Resident 72's September 2024 MAR (Medication Administration Record) revealed an order for Weights; weekly weights for 4 weeks, for weight monitoring for four administrations, with a start date of September 14, 2024.

Further review of Resident 72's September 2024 MAR revealed that no weights were obtained per the order above on September 14 and 28, 2024, or October 5, 2024.

Review of Resident 72's comprehensive care plan revealed a nutrition focus area with an intervention for weights as ordered, with an initiation date of July 9, 2024.

Electronic correspondence received from the Director of Nursing on March 5, 2025, at 2:44 PM, revealed she is unsure as to why weights were not obtained for Resident 72 as she was not at the facility.

Interview with the Nursing Home Administrator on March 6, 2025, at 10:07 AM, revealed she would have expected weights to have been obtained as ordered by the physician.

28 Pa code 211.12(d)(1)(3)(5) Nursing services



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

1. Facility is unable to retroactively obtain missed weekly weights for resident #72. Resident was being followed by Dietician and physican for lack of appetite. MD gave new order for remeron to encourage appetite. There does not appear to be any effects from weights not being obtained. Resident has slowly gained weight since September 2024.
2. Facility will conduct audit of current residents that have order for weekly weights to ensure the weights are being obtained as ordered.
3. DON/Designee will educate licensed nurses on Ftag 686 including need to obtain weights as ordered by physician.
4. DON/Designee will audit 10 residents weekly for 1 month, then monthly for 2 months to ensure weights are being obtained as ordered by physician. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.

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 clinical record reviews, observation, facility document review, and resident and staff interviews, it was determined that the facility failed to provide care and services in accordance with professional standards for four of 23 residents reviewed (Resident 5, 64, 68, and 88).

Findings include:

Review of Resident 5's clinical record revealed diagnoses that included vascular dementia (disease process in which damage to the blood vessels of the brain causes decreased contact with reality and decreased ability to perform activities of daily living) and congestive heart failure (decreased ability of the heart to pump blood through the body).

Review of Resident 5's clinical record revealed that on April 30, 2024, Resident 5 had a consultative gastrointestinal appointment for signs of dysphagia (difficulty swallowing).

Review of the consultation report revealed the recommendations stated, "Call with update in [two] weeks if [swallowing] no better Barium swallow next. Continue soft diet, thin liquids. Recommends dentures - see dentist." Review of the consultation sheet revealed it was signed by facility staff and the attending physician.

After Resident 5's April 30, 2024, appointment, facility staff documented that Resident 5 had coughing during meal consumption (sign and/or symptom of dysphagia) on May 9, 10, 11, 12, 13, and 14, 2024.

As of March 5, 2025, Resident 5 did not have a dental consult scheduled for the evaluation of dentures, did not have any further gastrointestinal appointments, nor any further speech therapy to address Resident 5's dysphagia despite the coughing episodes persisting.

Review of Resident 5's February, 2025 interdisciplinary progress notes revealed that staff documented that Resident 5 continued to have coughing episodes during or directly after meal consumption.

During a staff interview on March 6, 2025, the Nursing Home Administrator (NHA) revealed it was the facility's expectation that staff would have followed the recommendations provided by Resident 5's consultant gastrointestinal physician.

Review of Resident 64's clinical record revealed diagnoses that included contracture of muscle (a condition where muscles, tendons, joints, or other tissues tighten or shorten, causing deformity and loss of movement in the joint), functional quadriplegia (complete immobility due to severe disability or frailty caused by another medical condition, without physical injury or damage to the brain or spinal cord), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things).

Review of Resident 64's January 2025 TAR (Treatment Administration Record- documentation for medication/treatment administered or monitored) revealed three wound treatments on January 27, 2025, all of which were marked with a "9" rather than being checked to indicate they were administered. Further review of the TAR revealed "9" is a chart code for "other/see progress notes."

Review of Resident 64's progress notes on January 27, 2025, failed to reveal notation as to why the wound treatments were not completed on that date.

Review of Resident 64's February 2025 TAR revealed a daily wound treatment to his right medial shin, with a start date of December 21, 2024. Further review of his TAR revealed it was left blank on February 17, 2025, failing to indicate the treatment was completed.

During an interview with the Director of Nursing (DON) on March 6, 2025, at 10:14 AM, she revealed she was unable to provide information as to why the wound treatments were not documented as completed on January 27, 2025, and February 17, 2025; and she would expect wound treatments to be documented as completed, or notation in the clinical record why they were not completed.

Review of Resident 68's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply), type 2 diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin), and liver transplant.

Review of Resident 68's January physician orders revealed an order for Humulin 70/30 Insulin Suspension 100 units per ml (milliliters) inject 16 units subcutaneously every 8 hours for diabetes, dated January 5, 2025. The order did not indicate any parameters as to when insulin should not be administered.

Review of Resident 68's January 2025 Medication Administration Record (MAR) revealed the following:
1) January 16th 8:00 AM: dose was not administered, blood sugar was recorded as 68, and the insulin was coded as 14 (insulin not needed);
2) January 21st 8:00 AM: dose was not administered, no blood sugar was recorded, and the insulin was coded as 5 (Hold see progress note); and
3) January 23rd 8:00 AM: dose was not administered, no blood sugar was recorded, and the insulin was coded as 5 (Hold see progress note).

Review of Resident 68's January 2025 progress notes revealed the following:
1) there was no documentation on January 16, at 8:00 AM, indicating why the insulin was not administered or that Resident 68's physician was made aware that the insulin was not administered;
2) a progress note dated January 21, at 8:21 AM, that indicated "AM BS [blood sugar] low, resident refused breakfast", but failed to indicate if Resident 68's physician was made aware of the low blood sugar, Resident refusing breakfast, and insulin not being administered;
3) a progress note dated January 23, at 8:25 AM, that indicated the insulin was not administered "Due to low BS", but failed to indicate if Resident 68's physician was made aware of the low blood sugar and insulin not being administered.

Review of Resident 68's February 2025 physician orders revealed an order for Humulin 70/30 Insulin Suspension 100 units/ml (milliliters) inject 16 units subcutaneously every 8 hours for diabetes, dated February 20, 2025. This order did not indicate any parameters as to when insulin should not be administered.

Review of Resident 68's February 2025 MAR revealed the following:
1) February 20th 12:00 PM: dose was not administered, blood sugar was recorded as 89, and the insulin was coded as 5 (Hold see progress note);
2) February 21st 8:00 AM: dose was not administered, blood sugar was recorded as 112, and the insulin was coded as 5 (Hold see progress note);
3) February 21st 12:00 PM: dose was not administered, blood sugar was recorded as 112, and the insulin was coded as 5 (Hold see progress note);
4) February 24th 8:00 AM: dose was not administered, blood sugar was recorded as 122, and the insulin was coded as 5 (Hold see progress note); and
5) February 24th 12:00 PM: dose was not administered, blood sugar was recorded as 112, and the insulin was coded as 5 (Hold see progress note).

Review of Resident 68's February 2025 progress notes revealed the following:
1) a progress note dated February 20, at 2:05 PM, indicated that the insulin was not administered "due to low BS", but failed to indicate if Resident 68's physician was made aware of the low blood sugar and insulin not being administered;
2) a progress note dated February 21, at 9:49 AM, that indicated the insulin was not administered "due to low BS", but failed to indicate if Resident 68's physician was made aware of the low blood sugar and insulin not being administered;
3) a progress note dated February 21, at 1:27 PM, that indicated the insulin was not administered "due to low BS", but failed to indicate if Resident 68's physician was made aware of the low blood sugar and insulin not being administered;
4) a progress note dated February 24, at 9:24 AM, that indicated the insulin was not administered "Resident refused breakfast", but failed to indicate if Resident 68's physician was made aware that he had refused breakfast and insulin was not administered; and
5) a progress note dated February 24, at 1:08 PM, that indicated the insulin was not administered "Resident refused lunch", but failed to indicate if Resident 68's physician was made aware that he had refused lunch and insulin was not administered.

During a staff interview with the NHA and DON on March 6, 2025, at 10:12 AM, the DON confirmed that she would expect residents to receive their ordered insulin doses or physician notification to occur if a nurse felt the need to hold the insulin based on their nursing judgement.

Review of Resident 88's clinical record revealed diagnoses that included anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life) and psoriasis (a chronic skin condition characterized by raised, red, scaly patches of skin called plaque).

Review of Resident 88's clinical record revealed an active physician's order for: compression stockings, apply in the morning and remove at bedtime. Check every day and evening shift for Prevent DVT (Deep vein thrombosis - a blood clot that forms in a deep vein). Apply in the morning, with a start date of November 30, 2024.

Observation of Resident 88 on March 3, 2025, at 9:25 AM, and March 4, 2025, at 9:59 AM, revealed the Resident was laying in bed without compression stockings on.

Interview with Resident 88 on March 4, 2025, at 9:27 AM, revealed staff told her that she only needs to wear compression stockings if she is going to be out of bed for a few hours at a time.

Review of Resident 88's March 2025 MAR revealed that the order for compression stockings, apply in the morning and remove at bedtime. Check everyday and evening shift for prevent DVT, was marked off as being administered to Resident 88 on March 3, 2025, and March 4, 2025, during day shift.

Electronic correspondence received from the DON on March 5, 2025, at 3:40 PM, revealed that Resident 88 has been refusing compression stockings, but it has not been documented in progress notes.

Interview with the NHA on March 6, 2025, at 10:05 AM, revealed she would have expected staff to be marking if Resident 88 is refusing compression stockings on the MAR instead of marking that it is being completed.

28 Pa Code 201.18(b)(1) Management
28 Pa Code 211.12(d)(1)(3)(5) Nursing services



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

1-Resident 5 has been added to the list for the in-house dentist on 3/21/25. GI office will be contacted to schedule a follow up visit. Resident is being evaluated by speech therapy for dysphagia and coughing with meals. Resident being monitored for any further episodes of coughing with meals or directly after. Unable to retroactively complete missed wound treatment for resident 64 on January 27th and February 17th. Resident was assessed for any adverse effects related to missed wound treatments with no negative findings. MD made aware of missed treatments. Resident 68's primary physician was notified of held insulin due to low blood sugars on February 20, 21 and 24. Request made to primary physician to establish parameters for when it is appropriate to hold insulin. Unable to retroactively correct documentation of compression stockings not being applied due to refusal. Plan of care updated for resident 88 to reflect refusal of compression stockings and notification to MD to inquire if staff are to continue to offer and document refusals or if order for compression stockings needs to be discontinued.
2-Director of Nursing/designee will conduct a facility wide audit of current residents who:
Have returned from outside consulting appointments in the last 30 days with orders to schedule follow up to ensure follow up appointments have been made.
Are in need of follow up dental visits to ensure they are scheduled to be seen or have already been seen.
Have documented episodes of coughing or other difficulties with eating or drinking to ensure they are evaluated by speech therapy.
Have wound treatment orders to ensure all treatments have been completed in the last two weeks.
Have orders for insulin administration to ensure parameters are in place for when to hold insulin.
Have orders for compression stockings to ensure they are being applied and removed as per physician's orders and if not appropriate documentation and follow up is in place to note reason why they are not being applied.
3-Director of Nursing/designee will educate licensed nursing staff on Ftag 684 including importance of ensuring that all consults are followed up on and appointments scheduled as required, residents in need of dental follow up are scheduled to be seen by a dentist, any residents experiencing difficulty with eating/drinking are referred to speech therapy, residents with wound treatment orders have treatments completed as ordered or documentation with reason as to why wound treatment was not completed, residents with insulin orders have parameters as to when to hold insulin and residents with compression stockings get them applied and removed as per order or documentation and follow up if not being applied.
4-Director of Nursing/designee will conduct a random sample audit of 5 residents that return from appointments to ensure follow up appointments are scheduled, 5 residents with identified dental needs are scheduled to be seen by a dentist, 5 residents documented as having difficulties with eating or drinking are referred to speech therapy,
5 residents with wound treatment orders are receiving wound treatments as ordered or documentation as to why they were not completed, 5 residents with insulin orders have parameters as to when to hold insulin or documentation that MD was notified if held as a nursing measure and 5 residents with compression stockings have documented application and removal as ordered or documentation as to why they were not applied. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

§483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

§483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

§483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(k).
Observations:

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to notify the resident/resident representative of a resident's transfer, in writing, to include: the reason for the transfer or discharge, date of transfer, location of transfer, statement of the resident's appeal rights, name, and address (mailing and email) for two of four resident records reviewed for hospitalization (Residents 21 and 80).

Findings include:

Review of facility policy, titled "Bed-Holds and Returns," last reviewed February 3, 2025, revealed, in part, "3. Prior to a transfer, written information will be given to the residents and the resident representative that explain in detail: d. the details of the transfer (per the notice of transfer)."

Review of Resident 21's clinical record revealed diagnoses that included hypertensive heart disease
without heart failure (a long-term condition that develops over many years in people who have high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations).

Review of Resident 21's clinical record revealed that the Resident had been transferred and admitted to the hospital on June 3, 2024, and September 5, 2024.

Review of Resident 21's transfer notices dated June 4, 2024, and September 6, 2024, revealed that they were not signed by Resident 21 nor their Resident Representative, and there was no documentation on the notice of whom the information may have been reviewed with verbally. Further, they did not contain the mailing address of the Office of the State Long-Term Care Ombudsman; the mailing address for the agency responsible for protection and advocacy of individuals with developmental disabilities; nor, the mailing address for agency responsible for the protection and advocacy of individuals with mental disorders.

The facility was unable to provide documentation that Resident 21's transfers to the hospital on June 3, 2024, and September 5, 2024, were reported to the Ombudsman.

During a staff interview with the Nursing Home Administrator (NHA) on March 4, 2025, at 1:14 PM, the NHA indicated that when she started at the facility in December 2024, she could not find where there were any reports or emails to show that the Ombudsman reporting was being completed. She confirmed that she would expect the Ombudsman reporting to have been completed.

During a staff interview with the NHA on March 5, 2025, at 2:00 PM, the NHA confirmed that the transfer notices were not signed, and she had no documentation to provide of whom received the information contained in the transfer notice. She also confirmed that not all required info was included in transfer notice and should have been.

Review of Resident 80's clinical record revealed diagnoses that included type 2 diabetes mellitus (body's inability to use insulin causing sugar to build up in the blood) and Alzheimer's disease (progress disease that destroys memory and other mental functions).

Further review of Resident 80's clinical record revealed he was transferred out of the facility to the hospital on December 29, 2024, and was subsequently admitted to the hospital.

Additional review of Resident 80's clinical record failed to reveal a notice of transfer was provided to Resident 80 or his Representative.

During an interview on March 6, 2025, at 9:19 AM, with the NHA and Director of Nursing, it was revealed the facility had no additional information to provide. The NHA stated it was the expectation of the facility that notice of transfer be provided to residents and/or representatives.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(d)(2)(3)(5) Nursing services


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

1. Facility will provide transfer notices to residents 21 and 80. Facility had already identified n December 2024, that facility had not been sending transfers notice to LTC Ombudsman. Facility reviewed this through QAPI and has been compliant since December 2024 with monthly notification to LTC Ombudsman.
2. Facility will audit current residents with transfers to hospital in the previous 30 days. If facility did not provide transfer notices, these will be provided immediately.
3. NHA/Designee will provide education to licensed nurses on providing transfer notices to residents and/or resident representatives.
4. NHA/Designee will audit residents transferring to hospital for 3 months to ensure transfer notices have been provided. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr: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.
§483.15(d) Notice of bed-hold policy and return-

§483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under § 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

§483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on facility policy review, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure the resident and/or the resident's representative were provided the bed-hold notice upon transfer for two of four residents reviewed for hospitalizations (Residents 21 and 80).

Finding include:

Review of the facility policy, titled "Bed-Holds and Returns," last reviewed February 3, 2025, revealed, in part, "3. Prior to a transfer, written information will be given to the residents and the residents representatives that explains in detail: a. the rights and limitations of the resident regarding bed-holds; b. the reserve bed payment policy as indicated by the state plan (Medicaid resident); c. the facility per diem rate required to hold a bed (non-Medicaid resident), or to hold a bed beyond the state bed-hold period (Medicaid residents ..."

Review of Resident 21's clinical record revealed diagnoses that included hypertensive heart disease
without heart failure (a long-term condition that develops over many years in people who have high blood pressure), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), and chronic obstructive pulmonary disease (COPD-a type of progressive lung disease characterized by long term respiratory symptoms and airflow limitations).

Review of Resident 21's clinical record revealed that the Resident had been transferred and admitted to the hospital on June 3, 2024, and September 5, 2024.

Review of Resident 21's "Bed-Hold Policy and Notification and Authorization" notices dated June 3, 2024, and September 5, 2024, failed to include the bed-hold reserve payment rate.

During a staff interview with the Nursing Home Administrator (NHA) on March 5, 2025, at 2:00 PM, the NHA confirmed that the facility's Bed-Hold Policy and Notification and Authorization notices should include the bed-hold reserve payment rate.

Review of Resident 80's clinical record revealed diagnoses that included type 2 diabetes mellitus (body's inability to use insulin causing sugar to build up in the blood) and Alzheimer's disease (progress disease that destroys memory and other mental functions).

Further review of Resident 80's clinical record revealed he was transferred out of the facility to the hospital on December 29, 2024, and was subsequently admitted to the hospital.

Additional review of Resident 80's clinical record failed to reveal a bed-hold notification was provided to Resident 80 or his Representative.

During an interview on March 6, 2025 at 9:19 AM, with the NHA and Director of Nursing it was revealed the facility had no additional information to provide. The NHA stated it was the expectation of the facility that a bed-hold notification be provided to residents and/or representatives.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 211.12(d)(2)(3)(5) Nursing services


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


1. Facility will provide bed hold form to residents 21 and 80.
2. Facility will audit current residents with transfers to hospital in the previous 30 days. If facility did not provide bed hold forms, these will be provided immediately.
3. NHA/Designee will provide education to licensed nurses on providing bed hold forms to residents and/or resident representatives.
4. NHA/Designee will audit residents transferring to hospital for 3 months to ensure bed hold forms have been provided. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.

483.20(g) 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.
Observations:

Based on clinical record review and staff interviews, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 26 residents reviewed (Residents 64 and 72).

Findings include:

Review of Resident 64's clinical record revealed diagnoses that included contracture of muscle (a condition where muscles, tendons, joints, or other tissues tighten or shorten, causing deformity and loss of movement in the joint), functional quadriplegia (complete immobility due to severe disability or frailty caused by another medical condition, without physical injury or damage to the brain or spinal cord), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things).

Review of Resident 64's clinical record revealed he has been on a turning and repositioning program since his admission on December 13, 2024; and the intervention has been noted to be a part of his pain management program since December 14, 2024.

Review of Resident 64's Admission and 5 Day MDS assessments (Minimum Data Set- assessment tool utilized to identify residents' physical, mental and psychosocial needs) with ARD (assessment reference date- last day of the assessment period) of December 19, 2024, revealed Resident 64 was marked "no" under section J, "Received non-medication intervention for pain?", and was marked "no" under section M, "Turning/repositioning program."

During an email correspondence with the Nursing Home Administrator (NHA) on March 5, 2025, at 1:51 PM, she revealed Employee 9 (Licensed Practical Nurse Assessment Coordinator) revised the aforementioned MDS assessments to indicate that Resident 64 received non-medication intervention for pain and was on a turning/repositioning program during the ARD.

During a follow-up interview with the NHA on March 6, 2025, at 10:14 AM, she revealed she would expect Resident 64's MDS assessments to be coded accurately.

Review of Resident 72's clinical record revealed diagnoses that included hypotension (low blood pressure) and atrial fibrillation (an irregular heartbeat).

Review of Resident 72's clinical record revealed the Resident had an un-witnessed fall on September 20, 2024, and fell out of bed, with no injury occurring.

Review of Resident 72's Quarterly MDS dated October 16, 2024, revealed that Section J1800, Any Fall Since Admission/Entry/ or Reentry or Prior Assessment (Has the resident had any falls since admission/entry or reentry or the prior assessment) was marked No; as well as Section J1900, Number of Falls Since Admission/Entry or Reentry or Prior Assessment (A. Number of falls since Admission or Prior assessment - No Injury) failed to capture Resident 72's fall on September 20, 2024.

Electronic correspondence received from the NHA on March 5, 2025, at 1:53 PM, revealed Resident 72's Quarterly MDS completed on October 16, 2024, was corrected to reflect Resident 72's fall with no injury, and confirmed a modification was made on Section J1800 and Section J1900.

Interview with the NHA on March 6, 2025, at 10:05 AM, revealed she would have expected Resident 72's Quarterly MDS dated October 16, 2024, to have been coded accurately.

28 Pa. Code 211.5(f) Medical records
28 Pa Code 211.12 (d)(3)(5) Nursing Services


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

1. Assessments for residents 64 and 72 were corrected.
2. Audit will be conducted of most recent MDS completed for current residents to ensure accuracy of assessments including non-pharmacological pain interventions and fall history.
3. NHA/Designee will provide education to LPNC on F-tag 641 to ensure accuracy of assessments.
4. NHA/Designee will audit 5 MDS assessments weekly for 1 month, then monthly for 2 months to ensure accuracy of the resident assessment. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
§483.21(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 observations, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure the care plan was reviewed and revised for two of 26 residents reviewed (Residents 65 and 88).

Findings Include:

Review of Resident 65's clinical record revealed diagnoses that included congestive heart failure (a serious condition that occurs when the heart can't pump blood efficiently enough to meet the body's needs) and difficulty walking not elsewhere classified (a medical term used when someone has difficulty walking but the cause cannot be more precise).

Observation of Resident 65 on March 3, 2025, at 11:22 AM, revealed Resident 65 lying in bed, and Resident 65's rolling walker was sitting beside the Resident's bed. Interview with Resident 65 at that time revealed that she is able to walk with the rolling walker.

Review of Resident 65's care plan revealed a care plan with a focus area of, "Requires assistance transferring from one position to anther related to unsteady gait", with a revision date of January 8, 2025. The care plan failed to mention Resident 65's use of a rolling walker.

Interview with the Nursing Home Administrator (NHA) on March 5, 2025, at 2:55 PM, revealed that the rolling walker was on the care plan previously, but the care plan was revised and updated, and the previous version cannot be retrieved.

Review of Resident 88's clinical record revealed diagnoses that included anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life) and psoriasis (a chronic skin condition characterized by raised, red, scaly patches of skin called plaque).

Review of Resident 88's clinical record revealed she had an unwitnessed fall on December 27, 2024, where Resident 88 was found sitting on the floor beside her bed.

Review of Resident 88's comprehensive care plan revealed a focus area related to being at risk for falls with an intervention for fall matt(s): Left side of bed, with an initiation date of December 27, 2024.

Observations of Resident 88 on March 4, 2025, at 9:25 AM, and March 5, 2025, at 9:57 AM, revealed Resident 88 was in their room laying in bed, with no fall mat present on the left side.

Electronic correspondence received from the NHA on March 5, 2025, at 3:40 PM, revealed the fall mat was being removed from Resident 88's care plan as Resident 88 transfers independently in and out of bed.

Interview with the NHA on March 6, 2025, at 10:04 AM, revealed she would have expected Resident 88's fall mat to have been removed from their care plan if it was not in use.

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


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

1. Care plan was updated for resident #65 to include use of a rolling walker when ambulating. Care plan was updated for resident #88 to discontinue use of fall mat.
2. DON/Designee will conduct an audit of current residents with walkers and fall mats to ensure these are appropriate interventions and are on care plans.
3. DON/Designee will provide education to licensed nursing staff on Ftag 657 Care plan timing and Revision.
4. DON/Designee will audit 5 resident care plans weekly for 1 month and then monthly for 2 months to ensure care plans are appropriate for resident's status including resolution of care plans that are no longer applicable. s. Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.

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

Based on facility policy reviews, product information review, observations, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure care and services were provided in accordance with professional standards for two of six residents observed during medication preparation and administration for (Residents 25 and 65) and for one of one resident observed for treatment administration (Resident 68).

Findings include:

Review of facility policy, titled "Administering Medications," with a last review date of February 3, 2025, revealed,in part, "25. Staff follows established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications, as applicable."

Review of facility policy, titled "Insulin Administration," with a last review date of February 3, 2025, revealed, in part, "5. The nursing staff will have access to specific instructions (from the manufacturer if appropriate) on all forms of insulin delivery system(s) prior to their use."

Review of facility policy, titled "Pharmacy Services Policy and Procedure," with a last review date of February 3, 2025, revealed, in part, "Facility staff shall not borrow medication from another resident's supply. The practice of borrowing medication is not consistent with professional standards and contributes to medication errors."

Review of the instruction leaflet for Lantus-Solostar Insulin Pen, with a last revised date of February 23, 2016, revealed the following, in part: "Always use a new sterile needle for each injection. A. Wipe the rubber seal with alcohol. B. Remove the protective seal from a new needle. C. Line up the needle with the pen and keep it straight as you attach it (screw or push on, depending on the needle type)."

Review of Resident 25's clinical record revealed diagnoses that included hypertension (high blood pressure), chronic diastolic congestive heart failure (heart failure that occurs when the heart does not relax properly between beats, causing the heart to be unable to pump an adequate amount of blood to the body), and diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high).

Review of Resident 25's current physician orders revealed an order for Lantus SoloStar Subcutaneous Solution Pen-injector 100 units/ml (Insulin Glargine) Inject 20 unit subcutaneously in the morning for DM [Diabetes Mellitus], Give 1/2 dose if sugar less than 120, dated May 24, 2024.

During a medication pass observation on March 5, 2025, at approximately 8:41 AM, Employee 4 (Licensed Practical Nurse) was observed removing Resident 25's Lantus Solostar insulin pen from the medication cart, removing the cap on the insulin pen, and applying a new sterile needle to the pen. Employee 25 failed to cleanse the rubber seal prior to applying the new sterile needle. In addition, at approximately 8:55 AM, Employee 4 was observed administering Resident 25's Lantus insulin to her abdomen without wearing gloves.

Review of Resident 65's clinical record revealed diagnoses that included chronic systolic congestive heart failure (a specific type of heart failure that occurs in the left ventricle and the ventricle cannot contract normally when the heart beats) and diabetes.

Review of Resident 65's current physician orders revealed orders for Insulin Glargine Subcutaneous Solution 100 UNIT/ML (Insulin Glargine-Lantus) Inject 15 unit subcutaneously two times a day related to diabetes, dated February 20, 2025; and Insulin Lispro Injection Solution 100 UNIT/ML (Insulin Lispro) Inject 8 unit subcutaneously with meals related to diabetes, dated February 20, 2025.

During a medication pass observation on March 5, 2025, at approximately 9:02 AM, Employee 4 was observed removing Resident 65's Lantus SoloStar insulin pen and her Lispro insulin pen from the medication cart, removing the caps on the insulin pens, and applying a new sterile needle to the pens. Employee 4 failed to cleanse the rubber seals prior to applying the new sterile needle.

During a staff interview with Employee 4 on March 5, 2025, at 9:32 AM, he confirmed that he did not clean the insulin pens for Residents 25 and 65 prior to attaching the new sterile needle. He said that the pens were a closed system and did not need to be cleaned since he did not touch the end of the pens. He said that he had never been instructed that the end of an insulin pen should be cleansed with alcohol before applying the needle. Employee 4 further confirmed that he did not wear gloves while administering Resident 25's insulin. He said that if a person administers their own insulin, they do not have to wear gloves and, therefore, he did not wear gloves.

During a staff interview with the Nursing Home Administrator (NHA) on March 6, 2025, at 09:36 AM, the NHA confirmed that she would expect insulin pens to be cleaned before the needles are applied and that Employee 4 should have worn gloves when administering the insulin injection to Resident 25.

Review of Resident 68's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply), diabetes mellitus, and liver transplant.

Further review of Resident 68's clinical record revealed that he had a stage 2 pressure ulcer (a partial thickness tissue loss wound that does not go deeper than the dermis or middle layer of skin) on his right buttock; a stage 3 pressure ulcer (a full-thickness tissue loss wound where the tissue just under the skin may be visible, but no bone, tendon, or muscle is exposed) on his left buttock; and an unstageable pressure ulcer (full-thickness skin and muscle loss, with slough or eschar obstructing the wound bed making it impossible to determine the depth of the wound) on his sacrum (the part of the spinal column that is directly connected to the pelvis).

Review of Resident 68's current physician orders revealed orders to apply zinc oxide ointment to left and right buttock every shift for wound care, dated February 26, 2025; and cleanse sacrum with NSS (normal saline solution), apply Santyl (a medication used to remove debris or dead tissue from a burn, ulcer, or wound, which helps promote healing and decrease the risk of infection), and cover with a dry sterile dressing every day shift, dated February 20, 2025.

Observation of Resident 68's dressing change on March 5, 2025, at 12:52 PM, performed by Employee 5 (Licensed Practical Nurse) revealed that Employee 5 had prepared all treatment items prior to surveyor arrival. After the treatment observation was completed, at approximately 1:30 PM, Employee 5 was asked to provide the tube of Santyl she utilized to perform the treatment. Observation of this tube at approximately 1:30 PM, revealed that it was labeled with another resident's name.

During an immediate interview with Employee 5, she acknowledged the tube of Santyl had another resident's name on it.

In addition, the name on the tube was also verified by Employee 6 (Licensed Practical Nurse) and the Director of Nursing (DON) at 1:35 PM.

During a staff interview with the NHA and DON on March 6, 2025, at 10:09 AM, the DON confirmed that Employee 5 should have used Resident 68's tube of Santyl for his treatment.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services



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

1. Facility is unable to retroactively correct insulin administration for residents #25 and 65. Employee #4 was educated to ensure he cleanses rubber seal of insulin pen prior to applying new sterile needle. Education included need to wear gloves when administering insulin to residents. Facility is unable to retroactively correct treatment for resident #68. There were no adverse effects as the type of medication was as prescribed.
2. Facility will audit 10 current resident insulin administration to ensure licensed nurses are properly cleanses the rubber seal of insulin pen prior to applying new sterile needle and wear gloves during the insulin administration process through direct observation. Facility will audit 10 current resident treatments to ensure licensed nurses are using the resident's assigned treatments and not treatments belonging to another resident through direct observation.
3. DON/Designee will educate licensed nurses on F-tag 658 Services provided meet professional standards including need to properly cleanse the rubber seal of insulin pen prior to applying new sterile needle and wear gloves during the insulin administration process as well as ensuring they are using the resident's assigned treatments and not treatments belonging to another resident.
4. DON/Designee will audit 10 resident weekly for 1 month, then monthly for 2 months insulin administration to ensure licensed nurses are properly cleanses the rubber seal of insulin pen prior to applying new sterile needle and wear gloves during the insulin administration process Facility will audit 10 current resident treatments weekly for 1 month, then monthly for 2 months to ensure licensed nurses are using the resident's assigned treatments and not treatments belonging to another resident.Results of these audits will be reviewed by the Quality Assurance Performance Improvement committee.

483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a less serious (but not lowest level) deficiency and 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(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that residents receive necessary treatment and services, consistent with professional standards of practice, to identify pressure ulcers and to promote healing and prevent infection of a pressure ulcer for one of three residents reviewed for pressure ulcers (Resident 68).

Findings include:

Review of facility policy, titled "Dressings, Dry/Clean," with a last review date of February 3, 2025, revealed, in part, "15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward); 16. Use dry gauze to pat the wound dry; and 17. Apply the ordered dressing and secure with tape or bordered dressing per order."

Review of Resident 68's clinical record revealed diagnoses that included cerebral infarction (a stroke-damage to the brain from interruption of its blood supply), type 2 diabetes mellitus (disease that occurs when your blood glucose, also called blood sugar, is too high, but does not require the use of insulin), and liver transplant.

Further review of Resident 68's clinical record revealed that he had a stage 2 pressure ulcer (a partial thickness tissue loss wound that does not go deeper than the dermis or middle layer of skin) on his right buttock; a stage 3 pressure ulcer (a full-thickness tissue loss wound where the tissue just under the skin may be visible, but no bone, tendon, or muscle is exposed) on his left buttock; and an unstageable pressure ulcer (full-thickness skin and muscle loss, with slough or eschar obstructing the wound bed making it impossible to determine the depth of the wound) on his sacrum (the part of the spinal column that is directly connected to the pelvis).

Review of Resident 68's current physician orders revealed orders to apply zinc oxide ointment to left and right buttock every shift for wound care, dated February 26, 2025; and cleanse sacrum with NSS (normal saline solution), apply Santyl (a medication used to remove debris or dead tissue from a burn, ulcer, or wound, which helps promote healing and decrease the risk of infection), and cover with a dry sterile dressing every day shift, dated February 20, 2025.

Observation of Resident 68's dressing change on March 5, 2025, at 12:52 PM, performed by Employee 5 (Licensed Practical Nurse), revealed that Employee 5 cleansed all wounds with normal saline solution and a gauze pad, Employee 5 then applied the Santyl to the sacral wound utilizing a tongue depressor, applied the zinc oxide ointment to the buttock wounds, applied a foam bordered dressing to the sacrum, removed her gloves, washed her hands, and applied clean gloves to assist in repositioning Resident 68.

During a staff interview with the Nursing Home Administrator and Director of Nursing (DON) on March 6, 2025, at 10:09 AM, the DON confirmed that Employee 5 should have changed gloves, washed her hands, and applied clean gloves between cleansing Resident 68's wound and applying ordered treatment.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.10(d) Resident care policies
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services


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


Facility is unable to retroactively correct treatment administration for resident #68. Education was provided to employee #5.

The facility will conduct an audit of 10 current treatments to ensure licensed nurses are changing gloves, washing hands, and applying clean gloves between cleaning wounds and applying ordered treatments through direct observation.

DON/Designee will educate licensed nurses on Ftag 686 Treatment/Serves to prevent and heal pressure ulcers including the need to change gloves, wash hands, and apply clean gloves between cleaning wounds and applying ordered treatments.

Facility will audit 10 current resident treatments weekly for 1 month, then monthly for 2 months to ensure licensed nurses are changing gloves, washing hands, and applying clean gloves between cleaning wounds and applying ordered treatments through direct observation. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.
483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on facility policy review, clinical record review, observations, and staff interview, it was determined that the facility failed to provide respiratory care/oxygen services consistent with professional standards of practice for one of one resident reviewed for oxygen use (Resident 57).

Findings include:

Review of the facility policy, titled "Oxygen Administration," with a last review date of February 3, 2025, revealed, in part, "Verify that there is a physician's order for this procedure. Review the physician's orders or facility
protocol for oxygen administration."

Review of Resident 57's clinical record revealed diagnoses that included hypertension (high blood pressure), atrial fibrillation (abnormal heart rhythm characterized by rapid and irregular beating of the upper chamber of the heart), and cerebral infarction (a stroke-damage to the brain from interruption of its blood supply).

Observations of Resident 57 on March 3, 2025, at 11:01 AM, and March 4, 2025, at 11:00 AM, revealed that the Resident was receiving oxygen at 1 liter per minute via a nasal cannula.

Review of Resident 57's clinical record physician orders failed to reveal an order for oxygen administration.

During a staff interview with the Nursing Home Administrator on March 5, 2025, at 9:58 AM, she confirmed that Resident 57 was currently utilizing oxygen and that an order should have been in place for her oxygen use.

28 Pa code 211.12(d)(1)(2) Nursing services


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

1. Order for oxygen was obtained for resident # 57.
2. Facility will conduct audit of current residents to ensure if they have oxygen, that they have order by physician.
3. DON/Designee will educate licensed nurses on Ftag 695 including need to obtain order for oxygen by physician if they need oxygen.
4. DON/Designee will audit 10 residents weekly for 1 month, then monthly for 2 months to ensure if they are using oxygen, there is an order provided by physician. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.

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

Based on facility policy review, clinical record review, and resident and staff interviews, it was determined that the facility failed to ensure that pain management is provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents reviewed for pain management (Resident 64).


Findings include:

Review of facility policy, titled "Pain Assessment and Management", last reviewed February 3, 2025, read, in part, "The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is a multidisciplinary care process that includes the following: Developing and implementing approaches to pain management; identifying and using specific strategies for different levels and sources of pain; monitoring for the effectiveness of interventions; and modifying approaches as necessary. Non-pharmacological interventions may be appropriate alone or in conjunction with medications. Some non-pharmacological interventions include: a. Environmental - adjusting the room temperature, smoothing the linens, providing a pressure-reducing mattress, repositioning, etc.; b. Physical - ice packs, cool or warm compresses, baths, transcutaneous electrical nerve stimulation (TENS), massage, acupuncture, etc.; c. Exercise - range of motion exercises to prevent muscle stiffness and contractures; and d. Cognitive or Behavioral - relaxation, music, diversions, activities, etc. If pain has not been adequately controlled, the multidisciplinary team, including the physician, shall reconsider approaches and make adjustments as indicated. Report the following information to the physician or practitioner: significant changes in the level of the resident's pain; and prolonged, unrelieved pain despite care plan interventions."

Review of Resident 64's clinical record revealed he was admitted to the facility on December 13, 2024, with diagnoses that included contracture of muscle (a condition where muscles, tendons, joints, or other tissues tighten or shorten, causing deformity and loss of movement in the joint), functional quadriplegia (complete immobility due to severe disability or frailty caused by another medical condition, without physical injury or damage to the brain or spinal cord), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things).

Interview with Resident 64 on March 3, 2025, at 10:26 AM, revealed his pain level is consistently an 8 (out of 10), but when he receives his medicine, sometimes it goes down to a 5 or 6.

Review of Resident 64's physician orders revealed he had orders for both routine and PRN (as needed) pain medications.

Review of Resident 64's care plan revealed a focus area "At risk for pain" with an intervention for "Notify physician if pain frequency/intensity is worsening or if current analgesia regimen has become ineffective," with a start date of December 30, 2024.

Review of Resident 64's MAR (Medication Administration Record - documentation for medication/treatment administered or monitored) revealed he was administered a dose of as needed oxycodone (narcotic pain medication) on December 17, 2024, at 1:59 PM, and that his pain level was an 8.

Review of Resident 64's nursing progress notes revealed a note on December 17, 2024, at 1:59 PM, that stated "complained of general discomfort-rest/reposition ineffective."

Further review of Resident 64's nursing progress notes revealed a follow-up note linked to the aforementioned notes on December 17, 2024, at 4:47 PM, that stated "PRN administration was: ineffective. Follow-up pain scale was 7." No further as needed pain medication was administered that evening, no non-pharmacological interventions were noted to be effective, and no physician notification was noted in response to the prolonged, unrelieved pain.

Review of Resident 64's clinical record revealed from January 12, 2025, at 11:10 PM, until January 13, 2025, at 9:45 AM, his pain level was assessed four times during that period; all four times his pain level was noted to be at an 8.

Review of Resident 64's nursing progress notes revealed a note on January 13, 2025, at 3:50 AM, that stated, "Resident verbalized pain, requesting pain medication, Administered [at] 3:50 AM."

Review of Resident 64's nursing progress notes revealed a follow-up note linked to the aforementioned note on January 13, 2025, at 6:34 AM, that stated "PRN administration was: ineffective. Follow-up pain scale was 8."

Review of Resident 64's clinical record revealed he was administered as needed oxycodone on January 13, 2025, at 9:45 AM, and it was noted that rest and repositioning was ineffective for pain relief. No physician notification was noted in response to the prolonged, unrelieved pain.

Further review of Resident 64's nursing progress notes revealed a follow-up note linked to the aforementioned note on January 13, 2025, at 4:35 PM, that stated "PRN administration was: unknown [for effectiveness]."

Review of Resident 64's clinical record revealed he was administered as needed oxycodone on January 21, 2025, at 2:01 AM; a nursing progress note was linked to the medication administration that stated, "requested for complaint of lower back pain, repositioning not effective."

Further review of Resident 64's nursing progress notes revealed a follow-up note linked to the aforementioned note on January 21, 2025, at 5:33 AM, that stated "PRN administration was: ineffective. Follow-up pain scale was 6." No further as needed pain medication was administered that day, no non-pharmacological interventions were noted to be effective, and no physician notification was noted in response to the prolonged, unrelieved pain.

Review of Resident 64's clinical record revealed from February 21, 2025, at 11:56 AM, until February 21, 2025, at 10:03 PM, his pain level was assessed eight times during that period; all four times his pain level was noted to be at an 8.

Review of Resident 64's nursing progress notes revealed a progress note on February 21, 2025, at 11:30 AM, that he was given an as needed oxycodone medication that stated, "Complaints of general discomfort-rest/reposition ineffective."

Further review of Resident 64's TAR revealed he was given his as needed oxycodone every four hours as requested for pain, but that the as needed administrations were ineffective at relieving his pain, with a follow up pain scale of 8 at 11:56 AM, and 6:14 PM. No further as needed pain medication was administered that day, no non-pharmacological interventions were noted to be effective, and no physician notification was noted in response to the prolonged, unrelieved pain.

Review of Resident 64's clinical record on March 4, 2025, revealed the following physician orders for as needed pain medications:

Oxycodone HCl Oral Tablet 15 MG, Give one tablet by mouth every 4 hours as needed for moderate pain, max daily amount 90 mg, with a start date of December 13, 2024.

Hydromorphone (opioid pain medication) HCl Oral Tablet 2 MG, Give one tablet by mouth every 4 hours as needed for breakthrough pain, max daily Amount 12 mg, with a start date of December 13, 2024.

Ibuprofen (pain medication) Oral Tablet 400 MG, Give one tablet by mouth every 6 hours as needed for headaches, with a start date of December 13, 2024.

During an interview with Employee 7 (Licensed Practical Nurse) on March 4, 2025, at 1:06 PM, the surveyor questioned the process for administering the as needed pain medications. She revealed if Resident 64 continued with unrelieved pain after his routine pain medications are given, she administers the as needed oxycodone. If Resident 64 is still experiencing pain after he has received his as needed oxycodone, she will administer the as needed ibuprofen. She further revealed that she does not administer the as needed hydromorphone, because it hasn't been available in the medicine cart for quite some time.

During an email correspondence with the Director of Nursing (DON) on March 4, 2025, at 1:25 PM, the surveyor inquired if there should be numerical pain scales attached to the as needed oxycodone and hydromorphone so staff knows which medication to administer first, why the hydromorphone hasn't been available, and if the resident would benefit from having other non-pharmacological pain interventions that are being measured in their effectiveness of pain relief, other than rest/repositioning that is frequently noted to be ineffective.

Return email from the DON on March 4, 2025, at 5:27 PM, revealed they had added pain scales to the hydromorphone and oxycodone orders so staff knows which medication to administer first based on the residents pain level, and that the hydromorphone needs a new written prescription which is why it is not in the medication cart. She further revealed that she would follow-up with the physician for a new prescription for the medication, and that she has requested that Employee 9 (Licensed Practical Nurse Assessment Coordinator) review if Resident 64 would benefit from additional non-pharmacological pain interventions.

During an interview with Resident 64 on March 5, 2025, at 12:49 PM, he revealed he gets headaches and has a lot of pain, and sometimes it helps him to hold a cup of ice to his forehead and listen to music.

Review of Resident 64's physician orders on March 5, 2025, revealed pain scales of 5-7 for oxycodone administration, 8-10 for hydromorphone administration, and the following non-pharmacological pain interventions had been added to his as needed oxycodone and hydromorphone medication orders: "1. Reposition 2. Back rub 3. Music 4. Warm/cool compress 5. Diversional activity 6. Other (progress note)."

Interview with the DON on March 6, 2025, at 10:18 AM, revealed she would expect the pain medications to have pain scales for guidelines to administer the medications, and the facility should have notified the physician in response to days of prolonged unrelieved pain per his care plan intervention and facility policy. She further revealed that they should have reviewed the Resident for the potential of additional, measurable, non-pharmacological pain interventions, including the possibility to be seen by a pain clinic, and the interventions that have now been added to his physician orders.

During a follow-up interview with the DON on March 6, 2025, at 12:00 PM, the surveyor revealed the overall concern with Resident 64's regimen for pain management, lack of facility implemented effective non-pharmacological interventions to manage his pain, consistent use of as needed pain medications versus effective routine pain management, and lack of availability of one of his as needed pain medications for a severe pain level of 8-10. The DON verbalized her understanding, revealed the facility will be reaching out to the physician to inquire the ability to revise his pain management regimen, and stated that the only written prescription for hydromorphone that the facility had since his admission was from December 17, 2024, and there were only 28 tablets, so when the medication was no longer available, that is when the facility should have looked into other options for pain management.

28 Pa. Code 211.9(a)(1) Pharmacy services
28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services



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

1-Resident 64's pain regimen will review by his primary physician to ensure current pharmacological pain medications are appropriate for his expressed pain level and type. Non-pharmacological pain interventions that are effective for resident will be added to the orders to ensure non-pharmacological pain interventions are effective. Review of resident 64's pain medications reflect all ordered pain medications are available and present in the medication cart. Resident's plan of care has been updated to reflect his pain management needs and interventions.
2-Director of Nursing/designee will conduct a facility wide audit of current residents who have orders for PRN (as needed) pain medications to ensure they are being administered per order, have parameters as to when to administer each medication, are available in the facility, physician is notified if pain medications are not effective and non-pharmacological interventions are effective for the individual resident's pain management needs.
3-Director of Nursing/designee will educated licensed nursing staff on Ftag 697 and the importance of ensuring resident's pain management plan includes parameters as to when to administer which pain medications, are available in the facility, physician is notified when pain management is not effective and non-pharmacological pain interventions are effective for the resident's specific pain needs.
4-Director of Nursing/designee will conduct a random sample audit of 5 residents to ensure their pain management plan reflects parameters for pain medication as to when to administer which medication, medications are present and available, physician is notified when pain management is not effective and non-pharmacological pain interventions are effective for the resident's specific pain management needs. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.

483.25(n)(1)-(4) REQUIREMENT Bedrails: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(n) Bed Rails.
The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements.

§483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation.

§483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

§483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight.

§483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails.
Observations:

Based on policy review, observation, record review, and staff interviews, it was determined that the facility failed to complete a risk benefit analysis and obtain consent for enabler bar use for one of 23 residents reviewed (Resident 56).

Findings include:

Review of the facility policy, titled "Bed Safety" last reviewed February 3, 2025, revealed, "5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the attending physician, and input form the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use."

Review of Resident 56's clinical record revealed the diagnoses that included dementia (a chronic disorder of the mental processes caused by brain disease, marked by memory disorders, personality changes, and impaired reasoning) and acquired absence of the right and left leg above the knee (absence of a limb that has been removed due to trauma, medical condition, or surgery).

Observation of Resident 56's room on March 3, 2025, at 12:29 PM, revealed bilateral (on both sides) enabler bars.

Additional review of Resident 56's clinical record failed to reveal a consent for enabler bar use.

An email correspondence with the Director of Nursing (DON) on March 6, 2025, at 9:17 AM, revealed the facility was not able to provide a signed consent for Resident 56's enabler bar use.

During an interview with the Nursing Home Administrator and DON on March 6, 2025 at 9:51 AM, the DON stated it was the expectation of the facility that consent for enabler bar usage be obtained.

28 PA code 201.18(b)(1) Management
28 PA code 211.12(d)(1)(2)(3)(5) Nursing services


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

1. Consent for enabler bar usage was obtained for resident #56.
2. Facility will conduct audit of current residents with enabler bars to ensure consent for usage had been obtained
3. DON/Designee will educate licensed nurses on Ftag 700 including need to obtain consent for residents with enable bars.
4. DON/Designee will audit residents with enabler bars to ensure consent has been obtained weekly for 1 month, then monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.

483.45(c)(1)(2)(4)(5) REQUIREMENT Drug Regimen Review, Report Irregular, Act On: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(c) Drug Regimen Review.
§483.45(c)(1) The drug regimen of each resident must be reviewed at least once a month by a licensed pharmacist.

§483.45(c)(2) This review must include a review of the resident's medical chart.

§483.45(c)(4) The pharmacist must report any irregularities to the attending physician and the facility's medical director and director of nursing, and these reports must be acted upon.
(i) Irregularities include, but are not limited to, any drug that meets the criteria set forth in paragraph (d) of this section for an unnecessary drug.
(ii) Any irregularities noted by the pharmacist during this review must be documented on a separate, written report that is sent to the attending physician and the facility's medical director and director of nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified.
(iii) The attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record.

§483.45(c)(5) The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident.
Observations:

Based on clinical record review, policy review, and staff interviews, it was determined that the facility failed to act upon the licensed pharmacist's report of a medication recommendation, and failed to provide a monthly medication regimen review for one of five residents reviewed for unnecessary medications, psychotropic medications, and medication regimen review (Resident 23).

Findings include:

Review of the facility policy, titled "Consultant Pharmacist Reports: Medication Regimen Review (Monthly Report)", with a last review date of February 3, 2025, revealed, "The consultant pharmacist reviews the medication regimen of each resident at least monthly;" and "Physician accepts and acts upon suggestion or rejects and provides and explanation for disagreeing."

Review of Resident 23's clinical record revealed diagnoses that included anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life) and hypertension (high blood pressure).

Review of Resident 23's pharmacy recommendation dated July 12, 2024, revealed the consultant pharmacist's recommendation stated, "This resident is receiving lisinopril. Please ensure that a periodic cmp (comprehensive metabolic panel) is conducted to monitor this medication. Document of results should be accessible for review." Further review of the recommendation dated July 12, 2024, revealed the physician failed to provide a response.

Review of Resident 23's pharmacy recommendation dated September 16, 2024, revealed the consultant pharmacist's recommendation stated, "Orders for PRN (as needed) psychotropic drugs are limited to 14 days. Please evaluate if the PRN Lorazepam can be discontinued or add a stop/reassess date"; as well as the recommendation, "This resident has been receiving Lexapro 20 milligram (mg) daily, Remeron 15 mg at bedtime, Seroquel 25 mg AM and 75 mg 2 times a day, Ativan 1 mg every 8 hours as needed and 0.5 mg 2 times a day - please consider GDR (gradual dose reduction) - if GDR is clinically contraindicated at this time, please document that clinical rationale below." Further review of the recommendation dated September 16, 2024, revealed the physician failed to provide a response.

Review of Resident 23's pharmacy recommendation dated November 15, 2024, revealed the consultant pharmacist's recommendation stated, "Please add 'mix into 4 to 8 ounces of fluid to the polyethylene glycol order" as well as, "In addition to the over the counter pain management options, this resident has been receiving the following medication for long-term pain management: morphine 10 mg every 1 hour as needed. In an effort to eliminate unnecessary medications and prevent possible side effects associated with them, please evaluate the risk verse benefit of each medication, then discontinue all unnecessary medications, as you deem appropriate." Further review of the recommendation dated November 15, 2024, revealed the physician failed to provide a response.

Further review of Resident 23's monthly pharmacy recommendations revealed the facility was unable to provide evidence that Resident 23 had a pharmacy recommendation completed in December 2024.

Electronic correspondence received from the Director of Nursing on March 5, 2025, at 3:40 PM, revealed she was not able to provide a pharmacy recommendation for December 2024 for Resident 23, or any physician's responses to the recommendations made by the pharmacist in July 2024, September 2024, or November 2024.

Interview with the Nursing Home Administrator on March 6, 2025, at 10:06 AM, revealed she would have expected Resident 23 to have had a pharmacy recommendation completed in December 2024, and would have expected the physician to have responded to the recommendations for Resident 23 in July 2024, September 2024, and November 2024.

42 CFR 483.45 Drug Regimen Review
28 Pa. Code 211.9 (a)(1) Pharmacy services
28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services


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

1-Resident 23's recommendations for July 2024, September 2024 and November 2024 have been provided to physician for review and response. Request made to consulting pharmacist for resident 23's December 2024 pharmacy recommendations for review and follow up.
2-Director of Nursing/designee will conduct a facility wide audit of current resident's pharmacy recommendations for last month and current month to ensure pharmacy recommendations have been received and addressed with documented follow up.
3-Nursing Home Administrator will educate Director of Nursing, facility attending physician/s and Assistant Director of Nursing on Ftag 756 and the importance of ensuring pharmacy recommendations are received and addressed on a monthly basis with documented follow-up/response to recommendations.
4-Director of Nursing/designee will conduct a random sample audit of 5 residents to ensure monthly pharmacy recommendations are received, addressed and documented follow up of recommendations. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.

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 facility policy review, observation, and staff interview, it was determined that the facility failed to properly label and store prescribed medication or preventative creams in one of two treatment carts observed (Evergreen Way/Stepping Stones).

Findings include:

Review of facility policy, titled "Storage of Medications," with a last review date of February 3, 2025, revealed, in part, "2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers; 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner."

Review of facility policy, titled "Pharmacy Services Policy and Procedure," with a last review dated of February 3, 2025, revealed, in part, "Drugs and biologicals used in the facility shall be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable."

Observation of the Evergreen Way/Stepping Stones treatment cart on March 5, 2025, at 1:33 PM, with the Director of Nursing (DON) revealed that there were seven tubes of medication or preventative creams that were laying in the top drawer of the cart, outside of a box or bag labeled with a resident's name. Four of the tubes were noted to have a resident's name on them.

During an immediate staff interview with the DON, she indicated that the treatment creams/medications should have been stored in their proper packaging or individual bags with a resident's name clearly indicated.

28 Pa. Code 201.18(b)(1) Management
28 Pa. Code 211.9(a)(1) Pharmacy services


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

1.Evergreen Way/Stepping Stones treatment cart was checked, and all medication tubes have been placed in individual bags and properly labeled with resident's names.
2-Director of Nursing/designee will conduct a facility wide audit of all treatment carts to ensure all medications in treatment carts are appropriately stored in their original packaging or in a bag and labeled with resident's names.
3-Director of Nursing/designee will educate facility licensed staff on Ftag 761 and the importance of ensuring that all medications in treatment carts are appropriately stored in their original packaging or in a bag or box and labeled with the resident's name.
4-Director of Nursing/designee will conduct a random sample audit of 2 treatment carts to ensure medications are appropriately stored in their original packaging or in a bag or box and labeled with the resident's name. These audits will be conducted weekly for 4 weeks and monthly for 2 months. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on review of state regulations, review of the facility's reporting to the Patient Safety Authority, and staff interviews, it was determined that the facility failed to implement reporting patient specific healthcare associated infections to the Pennsylvania Patient Safety Authority, and failed to provide written notification to the resident and/or resident representative of healthcare associated infection(s).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L.154, No. 13), known as the "Medical Care Availability and Reduction of Error (Mcare) Act", Chapter 4, Section 308(b) "Reporting and notification," stated, "Duty to notify patient.--A medical facility through an appropriate designee shall provide written notification to a patient affected by a serious event [healthcare associated infection] or, with the consent of the patient, to an available family member or designee within seven days of the occurrence or discovery of a serious event."

Further, Chapter 4, Section 404(a) Health care facility reporting stated, "Nursing home reporting.--In addition to reporting pursuant to the Health Care Facilities Act, a nursing home shall also electronically report health care-associated infection data to the department and the authority using nationally recognized standards based on CDC definitions, provided that the data is reported on a patient-specific basis in the form, with the time for reporting and format as determined by the department and the authority."

On March 5, 2025, a request was made to the facility to provide evidence that the facility reported healthcare associated infections to the Pennsylvania Patient Safety Authority. Evidence that the resident and/or resident representative was notified of the healthcare associated infection was included with the request.

During a staff interview on March 6, 2025, at approximately 9:30 AM, Director of Nursing revealed that the facility was unable to provide evidence that the facility was notifying the Pennsylvania Patient Safety Authority of individual healthcare associated infections, nor was able to provide evidence that the resident or resident representative was provided written notice of the healthcare associated infections.

During a staff interview on March 6, 2025, at approximately 11:45 AM, Nursing Home Administrator revealed it was the facility's expectation that healthcare associated infections are reported to the Pennsylvania Patient Safety Authority and to the resident/resident representative per regulatory requirements.


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

1. Facility is unable to retroactively correct not reporting to Pennsylvania Patient Safety Authority and not providing written notice to resident or resident representative of healthcare associated infections.
2. Facility will submit February 2025 healthcare acquired infections to the Pennsylvania Patient Safety Authority and residents or resident representatives will be notified.
3. Facility's Infection Control Preventionist will be educated by DON/Designee on Tag 1020 including ensuring healthcare acquired infections are reported to the Pennsylvania Patient Safety Authority and residents or resident representatives are to be notified.
4. DON/Designee will audit all residents with new healthcare acquired infections weekly for 1 month and then monthly for 2 months to ensure residents or resident representative have been notified. DON/Designee will audit monthly for 3 months to ensure healthcare acquired infections are reported to the Pennsylvania Patient Safety Authority. Results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for recommendations.


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