Pennsylvania Department of Health
 SOUTHWESTERN VETERANS CENTER
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
SOUTHWESTERN VETERANS CENTER
Inspection Results For:

There are  142 surveys for this facility. Please select a date to view the survey results.

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SOUTHWESTERN VETERANS CENTER - 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, and an Abbreviated survey in response to three complaints/events completed on April 25.2025, it was determined that Southwestern Veterans Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on review of facility policy, group interview, observations of resident areas and nursing units, and staff interviews it was determined that the facility failed to ensure anonymous grievance boxes are readily accessible for resident use on three of three floors (Second, Third, and Fourth Nursing Floor).

Findings include:

The facility "Resident Rights" policy dated 1/16/25, indicated that the resident has the right to make a complaint to the staff of the nursing home, or any other person, without fear of punishment or reprisal. The nursing home must address the issue promptly.

During an observation on 4/21/25, at 2:30 p.m. no grievance boxes were located on the Second Nursing Floor where residents, resident representatives, or visitors could utilize, if needed.

During an observation on 4/21/25, at 2:36 p.m. no grievance boxes were located on the Third Nursing Floor where residents, resident representatives, or visitors could utilize, if needed.

During an observation on 4/21/25, 2:41 p.m. no grievance boxed were located on the Fourth Nursing Floor were residents, resident representatives, or visitors could utilize, if needed.

During an observation on 4/21/25, at 2:45 p.m. an anonymous grievance box was observed in the lobby hall sitting on a ledge with six wheelchairs being stored in front of it. The anonymous grievance box was not readily accessible to anyone at this time.

During an interview on 4/21/25, at 2:49 p.m. the Assistant Nursing Home Administrator Employee E10 confirmed that the anonymous grievance box was in the lobby hallway and that there are no other grievance boxes throughout the facility that are readily accessible to residents, resident representatives, or visitors.

During an interview on 4/21/25, at 2:51 the Assistant Nursing Home Administrator Employee E10 confirmed that the anonymous grievance box in the lobby hallway was blocked by six wheelchairs and was not readily accessible.

During an interview on 4/22/25, at 9:31 a.m. Social Worker, Grievance Officer, Employee E4 stated, "I'm not familiar with any grievance boxes on the nursing floors. There is something down on the first floor but I'm not sure where its at". Residents usually come to me to file a grievance.

During a group interview on 4/22/25, at 11: 00 a.m. three out of seven residents during a group meeting did not know where to find a grievance box in the facility, stated no grievance boxes were on the units, all you do is give your grievance to the social worker, and were unsure of how to file a grievance anonymously.

During an interview on 4/22/25, at 3:00 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure anonymous grievance boxes are readily accessible for resident, resident representative, and visitor use on three of three floors (Second, Third, and Fourth Nursing Floor).

28 Pa. Code 201.18e(4)Management.
28 Pa. Code 201.29(a)Resident rights.





 Plan of Correction - To be completed: 06/04/2025

Facility had anonymous grievance box available for residents to file a grievances in an accessible location on the first floor. Wheelchairs that were temporarily blocking the box were removed and access was available

6 additional grievances boxes were ordered by facility and will be placed in the resident lounges on each unit

Education will be completed with grievance coordinator at the facility by NHA/designee on regulation F585 Grievances

Audits will be completed weekly x4 weeks and monthly x2 months on accessibility of resident anonymous grievances boxes

Audit results will be reported to the QAPI committee for review

483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and 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.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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

Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for five of eight residents (Residents R13, R16, R21, R91, and R104).

Findings include:

Review of the facility policy "Permitted Charges for Medical Records" dated 1/16/25, indicated the medical record is an accounting of events and interactions between an individual and a healthcare provider. Medical records assist in analyzing trends in healthcare use, an individual's characteristics and quality of care.

Review of the facility job description "Registered Nurse (RN)" indicated the RN is to record daily care performed for the residents on the appropriate forms and the approved electronic medical record and establish and maintain effective communication with resident, family, and staff.

Review of Resident R13's clinical record indicated the resident was admitted to the facility on 9/26/22.

Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/3/25, indicated the diagnoses of coronary artery disease (narrow arteries decreasing blood flow to heart), hypertension (the force of the blood against the artery walls is too high), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident R13's current physician orders on 4/23/25, indicated check and record vitals (temperature, pulse, blood pressure, oxygen saturation, respirations, and weight) on the fifth of each month per facility policy. Special instructions - weights can be started at the beginning of each month; weight and vitals are due to be completed and recorded by the fifth of each month.

Review of Resident R13's weight record in the Electronic Medical Record (EMR) on 4/23/25, at 1:15 p.m., failed to include a documented weight for the month of April 2025.

Interview on 4/24/25, at 3:05 p.m. Registered Dietitian Employee E7 confirmed that the weights should be entered into the EMR, and the facility failed to maintain complete and accurate documentation for Resident R13.

Review of the clinical record indicated Resident R16 was admitted to the facility on 2/15/07.

Review of Resident R16's MDS dated 3/27/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood).

Review of a physician order dated 2/13/23, indicated to check and record vitals (temperature, pulse, blood pressure, oxygen saturation, respirations, and weight) on the 5th of each month, per facility policy. Weights can be started at the beginning of each month; weights and vitals are due to be completed and recorded by the 5th of each month.

Review of Resident R16's weight record in the EMR on 4/23/25, failed to include a documented weight for the month of December 2024.

Review of Resident R16's December 2024 Medication Administration Record (MAR) indicated the resident's weight was not performed on 12/5/24, as ordered. The documented reason was, "already complete".

During an interview on 4/23/25, at 2:57 p.m. Registered Dietitian Employee E7 confirmed Resident R16's weight was not documented in the EMR and that the facility failed to maintain complete and accurate documentation for Resident R16.

Review of the clinical record indicated Resident R21 was admitted to the facility on 3/5/18.

Review of Resident R21's MDS dated 3/6/25, indicated diagnoses of constipation, hypocalcemia (low levels of calcium in the blood), and Vitamin D deficiency.

Review of a progress note dated 4/6/25, completed by RN Employee E16 stated, "Resident continues to have menial tasks for staff that she requests one at a time. She first had RN go to her room on her way back in her wheelchair. Then, 2 minutes after RN left her room, she rang the call light. Resident seems to be anxious and incessantly wants staff in her room. In addition to the call bell, resident calls the nurses station from her phone. She flags down staff as they are walking down the hall near her. Her request are for the staff to take whatever food as a snack, she wants to talk/tell stories, she wants pulled up (even though she is a good foot and a half from the bottom of the bed and would hit her head if she were laying down and not sitting up), then she complains about her brief after she is pulled up (staff will continuously fix her location in the bed and then her brief (when one is fixed, the other bothers her and it is a continuous cycle). Resident just continuously has small requests, one at a time, continuously calling staff, or hunting them down. Resident continuously asked to make all needs known at one time."

Review of a progress note dated 4/19/25, completed by RN Employee E17 stated, "Resident continues to seek staff assistance/attention each time she sees someone. If resident sees someone near the door, walk by, or hears a voice, she will yell for them repeatedly. When staff acknowledge that they will be over when they are finished assisting the resident they are currently with, she acts like she does not hear it and continues to yell. However, she "can hear" fine other times. Then if another staff member is seen or heard, she continues to yell for them. All needs are met each time. She is fed, has a variety of drinks, is comfortable, clean and dry. She asks for multiple tasks to be completed at the same time. She will wait right beside the medication cart, resident, phone, or nurse's station while nursing is assisting another resident or on the phone and obsessively find a reason for attention. Most of the time, it is a request that could have waited until it was her turn again. She continues to monopolize each staff members time to the extent of her ability to do so."

During an interview on 4/25/25, at 9:35 a.m. the Director of Nursing (DON) confirmed that the facility failed to chart accurately and appropriately for Resident R21 as required.

Review of Resident R91's clinical record indicated the resident was admitted to the facility on 8/22/19.

Review of Resident R91's MDS dated 3/20/25, indicated the diagnoses of Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), Parkinson's Disease (disorder of the nervous system that results in tremors), and depression.

Review of Resident R91's current physician orders on 4/23/25, indicated check and record vitals (temperature, pulse, blood pressure, oxygen saturation, respirations, and weight) on the fifth of each month per facility policy. Special instructions - weights can be started at the beginning of each month; weight and vitals are due to be completed and recorded by the fifth of each month.

Review of Resident R91's weight record in the Electronic Medical Record (EMR) on 4/23/25, at 2:00 p.m., failed to include a documented weight for the month of April 2025.

Interview on 4/24/25, at 3:05 p.m. Registered Dietitian Employee E7 confirmed that the weights should be entered into the EMR, and the facility failed to maintain complete and accurate documentation for Resident R91.

Review of the clinical record indicated Resident R104 was admitted to the facility on 11/28/23.

Review of Resident R104's MDS dated 2/13/25, indicated diagnoses of high blood pressure, hyperlipidemia, and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood).

Review of a physician order dated 11/28/23, indicated to obtain monthly weight. Special instructions: monthly weights are to be completed by the 5th day of every month and reweighed if +5 or -5 pound difference.

Review of Resident R104's weight record in the EMR on 4/23/25, failed to include a documented weight for the month of November 2024.

Review of Resident R104's November 2024 MAR indicated the resident's weight was not performed on 11/5/24, as ordered. The documented reason was, "already done".

During an interview on 4/23/25, at 2:57 p.m. Registered Dietitian Employee E7 confirmed Resident R104's weight was not documented in the EMR and that the facility failed to maintain complete and accurate documentation for Resident R104.

Review of a progress note dated 4/21/25, completed by RN Employee E17 stated, "Resident has excessively rang the call bell this morning. Each time staff enter, he whines with something he wants done. Multiple staff have assisted resident and asked if there is anything else they can do prior to leaving the room. Resident states no and then would ring the call bell very soon again. Resident is Clean and dry, he has been fed and provided with beverages, he has been repositioned, he had PRN (as needed) analgesics this AM."

During an interview on 4/25/25, at 9:35 a.m. the DON confirmed that the facility failed to chart accurately and appropriately for Resident R104 as required.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.5(f) Medical records.
28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.




 Plan of Correction - To be completed: 06/04/2025

Resident R13's weight was entered into the electronic medical record for April 2025

Resident R16's weight was entered into the electronic medical record for December 2024

Resident R91's weight was entered into the electronic medical record for April 2025

Resident R104's weight was entered into the electronic medical record for November 2024

Residents weight entries were reviewed for the month of May 2025 for entry/completion

Resident R21's progress note reviewed with involved staff member by the facility Nurse Administrator

Resident R91's progress note reviewed with involved staff member by the facility Nurse Administrator

Resident R104's progress note reviewed with involved staff member by the facility Nurse Administrator


Licensed nursing staff will receive education on the facility Weight policy from the Registered Nurse Instructor/designee.

The staff involved with failure to chart accurately and appropriately received education regarding progress notes related to standards of professional practice for appropriate communication from the facility Nurse Administrator/designee

Licensed nursing staff will receive education for appropriate and professional documentation from the Registered Nurse Instructor/designee.

Random audits on 5 resident weight entries will be completed weekly x4 weeks and monthly x2 months

Random progress notes on 5 residents charts will be reviewed weekly x4 weeks and monthly x2 months to ensure standards of professional practice for appropriate documentation

Audit results will be reported to the QAPI committee for review

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning: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(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 review of facility policy, observations, staff interviews, and clinical record review, it was determined that the facility failed to provide appropriate respiratory care for three of five residents (Residents R13, R31, and R51).

Findings include:

Review of facility policy "Supplemental Oxygen Therapy" dated 1/16/25, indicated used cannulas, masks, and tubing shall be stored in a plastic bag, off the floor, labeled with the Resident's name, when not in use.

Review of facility policy "Noninvasive Ventilation: BiPAP, CPAP" dated 1/16/25, indicated when not in use, assembled headgear, masks, and tubing shall be stored in a plastic bag, labeled with the resident's name and date.

Review of Resident R13's clinical record indicated the resident was admitted to the facility on 9/26/22.

Review of Resident R13's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/3/25, indicated the diagnoses of coronary artery disease (narrow arteries decreasing blood flow to heart), hypertension (the force of the blood against the artery walls is too high), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident R13's physician order dated 3/4/25, indicated BiPAP equipment care to be completed every week on Sundays, on daylight shift, that includes replacing the storage bag for mask, tubing, and headgear and label with resident' s name and current date.

During an observation on 4/21/25, at 9:27 a.m. Resident R13's BiPAP machine was observed on the nightstand beside the bed with the BiPAP mask sitting beside it, not in the storage bag as required.

During an interview on 4/21/25, at 10:00 a.m. Registered Nurse (RN) Employee E15 confirmed Resident 13's BiPAP was not properly stored in a plastic bag while not in use and the facility failed to provide appropriate respiratory care for Resident R13.

Review of Resident R31's clinical record indicated the resident was admitted to the facility on 10/22/24.

Review of Resident R31's MDS dated 2/5/25, indicated diagnoses of peripheral vascular disease (PVD, circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), depression, and sleep apnea (a condition when you stop breathing while your sleeping).

Review of a physician order dated 3/4/25, indicated a BiPAP with six liters of oxygen to be administered every night at bedtime.

Review of a physician order dated 3/4/25, indicated BiPAP equipment care to be completed every week on Sundays, on daylight shift, that includes replacing the storage bag for mask, tubing, and headgear and label with resident ' s name and current date.

During an observation on 4/21/25, at 10:25 a.m. Resident R31's BiPAP machine was observed on the nightstand beside the bed with the BiPAP mask sitting beside it. No storage bag was observed.

During an interview on 4/21/25, at 10:29 a.m. Licensed Practical Nurse Employee E9 confirmed Resident R31's BiPAP was not properly stored in a plastic bag while not in use and the facility failed to provide appropriate respiratory care for Resident R31.

Review of the clinical record indicated Resident R51 was admitted to the facility on 12/11/18.

Review of Resident R51's MDS dated 3/27/25, indicated diagnoses of high blood pressure, Chronic Obstructive Pulmonary Disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions).

Review of a physician order dated 7/12/24, indicated to administer oxygen up to 6 liters via nasal cannula as needed to maintain oxygen saturation levels between 88% to 92%.

Review of a physician order dated 7/12/24, indicated to clean oxygen concentrator filter and change and label the following with date weekly on Sunday evening shift. 1. Nasal cannula tubing/mask/neb tubing. 2. Distilled water container. 3. Plastic storage bag(s), label with resident name in addition.

Review of a physician order dated 2/27/25, indicated to assist resident with doffing (removing) CPAP upon awakening. Empty humidifier chamber of any remaining water. Place mask/tubing/headgear into plastic labeled storage bag.

During an observation on 4/21/25, at 10:10 a.m. Resident R51's nasal cannula was observed lying on the floor to the left of the resident's bed. During this observation, Resident R51's CPAP machine was observed on a bedside table to the right of the bed. The CPAP mask was observed sitting on top of the machine.

During an observation on 4/21/25, at 10:38 a.m. Resident R51's nasal cannula tubing was observed wrapped around the oxygen flow meter, now off of the floor. During this observation, Infection Preventionist Employee E1 was informed that the nasal cannula was previously observed on the floor.

During an interview on 4/21/25, at 10:38 a.m. Infection Preventionist Employee E1 confirmed Resident R51's nasal cannula and CPAP were not properly stored in a plastic bag while not in use and that the facility failed to provide appropriate respiratory care for Resident R51.

Review of Resident R51's care plan on 4/22/25, failed to include the development of a plan of care and interventions for the resident's oxygen therapy and CPAP therapy.

During an interview on 4/23/25, at 12:09 p.m. Registered Nurse Assessment Coordinator Employee E6 confirmed that the facility failed to develop a plan of care and interventions related to Resident R51's oxygen and CPAP therapy.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(c)(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(2)(3)(5) Nursing services.





 Plan of Correction - To be completed: 06/04/2025

Resident R13's Bipap mask was placed in a storage bag as per facility policy.

Resident R31's Bipap mask was placed in a storage bag as per facility policy.

Resident R51's nasal cannula was replaced, and storage bag was provided; the CPAP mask was placed in a storage bag as per facility policy.

Resident R51's care plans were reviewed and updated to include Oxygen/CPAP therapy.

Other residents ordered Oxygen therapy were reviewed for appropriate storage of Oxygen delivery devices.

Registered Nurse Assessment Coordinators will receive education on facility care plan policy from the Registered Nurse Instructor/designee

Licensed nursing staff will receive education for storage of oxygen delivery devices based on the BVH Supplemental Oxygen Therapy policy from the Registered Nurse Instructor/designee.

Random audits of care plans for 10 residents receiving oxygen therapy will be completed weekly x4 weeks and monthly x2 months for proper storage

Random audits of 5 residents respiratory supplies will be audited for proper storage weeklyX4 weeks and monthly x 2 months

Audit results will be reported to the QAPI committee for review

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 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.
§483.15(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 clinical record review and staff interviews, it was determined that the facility failed to notify the resident or resident's representative of the facility bed-hold policy (an agreement for the facility to hold a bed for an agreed upon rate during a hospitalization) for five of six resident hospital transfers (Residents R16, R19, R38, R128, and R166).

Findings include:

Review of the clinical record indicated Resident R16 was admitted to the facility on 2/15/07.

Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood).

Review of the clinical record indicated Resident R16 was transferred to the hospital on 4/14/25, and remained out to the hospital during review on 4/24/25.

Review of Resident R16's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital, or within 24 hours of the transfer to the hospital on 4/14/25.

Review of the clinical record indicated Resident R19 was admitted to the facility on 12/28/22.

Review of Resident R19's MDS dated 3/13/25, indicated diagnoses of atrial fibrillation (irregular heart rhythm), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs).

Review of the clinical record indicated Resident R19 was transferred to the hospital on 1/28/25.

Review of Resident R19's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital, or within 24 hours of the transfer to the hospital on 1/28/25.

Review of Resident R38's clinical record indicated the resident was admitted to the facility on 8/21/13.

Review of Resident R38's MDS dated 3/17/25, indicated diagnoses of cancer (an uncontrolled growth and division of abnormal cells), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and, diabetes.

Review of the clinical record indicated Resident R38 was transferred to the hospital on 2/15/25.

Review of Resident R38's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital, or within 24 hours of the transfer to the hospital on 2/15/25.

Review of Resident R128's clinical record indicated the resident was admitted to the facility on 6/7/23.

Review of Resident R128's MDS dated 3/3/25, indicated diagnoses of dry eye syndrome, hearing loss, and repeated falls.

Review of the clinical record indicated Resident R128 was transferred to the hospital on 3/3/25.

Review of Resident R128's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital, or within 24 hours of the transfer to the hospital on 3/3/25.

Review of Resident R166's clinical record indicated the resident was admitted to the facility on 11/27/24.

Review of Resident R166's MDS dated 12/3/24, indicated diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and heart failure (a progressive heart disease that affects pumping action of the heart muscles).

Review of the clinical record indicated Resident R166 was transferred to the hospital on 2/23/25.

Review of Resident R166's clinical record failed to include documented evidence that the resident or the resident's representative were provided with written information about the facility's bed hold policy at the time of the transfer to the hospital, or within 24 hours of the transfer to the hospital on 2/23/25.

During an interview on 4/24/25, at 2:46 p.m. the Director of Nursing confirmed that the facility failed to notify the resident or resident's representative of the facility bed-hold policy for five of six resident hospital transfers as required.

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



 Plan of Correction - To be completed: 06/04/2025

Resident R16 returned to facility on 04/27/2025 bed hold notice was provided to resident upon transfer out to the hospital but was not documented in nursing note

Resident R19 returned to the facility on 03/30/2025 bed hold notice was provided to resident upon transfer out to the hospital but was not documented in nursing note

Resident R38 returned to the facility 03/07/2025 bed hold notice was provided to resident upon transfer out to the hospital but was not documented in nursing note

Resident 128 returned to the facility 03/05/2025 bed hold notice was provided to resident upon transfer out to the hospital but was not documented in nursing note

Resident 166 was transferred to the hospital 2/14/2025 and expired at the hospital 2/23/2025 bed hold notice was provided to resident upon transfer out to the hospital but was not documented in nursing note

Licensed nursing staff members will receive education by the registered nurse instructor/designee to provide appropriate documentation for resident hospital transfers that will include bed hold policy, POLST, face sheet and Continuity of Care document.

Random audits of 5 residents transferred to another facility will be completed weekly x4 and monthly x 2 to ensure appropriate documentation was sent with the resident upon transfer

Audit results will be reported to the QAPI committee for review

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge: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.
§483.15(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 clinical record review and staff interviews, it was determined that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five of five residents (Residents R16, R38, R104, R128, and R166).

Findings include:

Review of the clinical record indicated Resident R16 was admitted to the facility on 2/15/07.

Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood).

Review of the clinical record indicated Resident R16 was transferred to the hospital on 4/14/25.

Review of Resident R16's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 4/14/25.

Review of Resident R38's clinical record indicated the resident was admitted to the facility on 8/21/13.

Review of Resident R38's MDS dated 3/17/25, indicated diagnoses of cancer (an uncontrolled growth and division of abnormal cells), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and, diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).

Review of the clinical record indicated Resident R38 was transferred to the hospital on 2/15/25.

Review of Resident R38's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 2/15/25.

Review of the clinical record indicated Resident R104 was admitted to the facility on 11/28/23.

Review of Resident R104's MDS dated 2/13/25, indicated diagnoses of high blood pressure, hyperlipidemia, and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood).

Review of the clinical record indicated Resident R104 was transferred to the hospital on 3/26/24.

Review of Resident R104's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 3/26/25.

Review of Resident R128's clinical record indicated the resident was admitted to the facility on 6/7/23.

Review of Resident R128's MDS dated 3/3/25, indicated diagnoses of dry eye syndrome, hearing loss, and repeated falls.

Review of the clinical record indicated Resident R128 was transferred to the hospital on 3/3/25.

Review of Resident R128's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 3/3/25.

Review of Resident R166's clinical record indicated the resident was admitted to the facility on 11/27/24.

Review of Resident R166's MDS dated 12/3/24, indicated diagnoses of high blood pressure, anemia (too little iron in the body causing fatigue), and heart failure (a progressive heart disease that affects pumping action of the heart muscles).

Review of the clinical record indicated Resident R166 was transferred to the hospital on 2/23/25.

Review of Resident R166's clinical record, the facility failed to include documented evidence that the facility provided a written transfer notification to the Office of Long-Term Care Ombudsman for the hospitalization on 2/23/25.

During an interview on 4/22/25, at 12:27 p.m. Social Work Director Employee E4 stated that the facility only notifies the local ombudsman of resident transfers.

During an interview on 4/22/25, at 12:27 p.m. Social Work Director Employee E4 confirmed that the facility failed to provide a transfer notice to a representative of the Office of the Long-Term Care Ombudsman Division for five of five residents as required.

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



 Plan of Correction - To be completed: 06/04/2025

R16 returned from the hospital to the facility on 04/27/25 (Written notification was sent to the local ombudsman office not the office of the State Long-Term Care Ombudsman) upon identification notice was sent to office of the State Long-Term Care Ombudsman

R38 returned from the hospital to the facility on 03/07/25 (Written notification was sent to the local ombudsman office not the office of the State Long-Term Care Ombudsman) upon identification notice was sent to office of the State Long-Term Care Ombudsman

R 104 returned from the hospital to the facility on 04/03/25 (Written notification was sent to the local ombudsman office not the office of the State Long-Term Care Ombudsman) upon identification notice was sent to office of the State Long-Term Care Ombudsman

R 128 returned from the hospital to the facility on 03/05/25 (Written notification was sent to the local ombudsman office not the office of the State Long-Term Care Ombudsman) upon identification notice was sent to office of the State Long-Term Care Ombudsman

R 166 CTB at the hospital on 03/23/25 (Written notification was sent to the local ombudsman office not the office of the State Long-Term Care Ombudsman) upon identification notice was sent to office of the State Long-Term Care Ombudsman

Like residents being sent out to the hospital or discharged from the facility notification of transfer will be sent to the office of the state long term care ombudsman division

Education will be completed with medical records staff by NHA/designee on the requirements of the office of the state long term care ombudsman division notification for transfer/discharge

Audits will be completed weekly x4 weeks and monthly X2 months on the requirements of office of the state long term care ombudsman division notification for transfer/discharge

Audit results will be reported to the QAPI committee for review


483.15(c)(1)(i)(ii)(2)(i)-(iii) REQUIREMENT Transfer and Discharge Requirements: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.
§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A) The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B) The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D) The health of individuals in the facility would otherwise be endangered;
(E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F) The facility ceases to operate.
(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i) Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents sampled with facility-initiated transfers (Residents R16, R19, and R38).

Findings include:

Review of the clinical record indicated Resident R16 was admitted to the facility on 2/15/07.

Review of Resident R16's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/27/25, indicated diagnoses of high blood pressure, anemia (too little iron in the blood), and hyperlipidemia (high levels of fat in the blood).

Review of the clinical record indicated Resident R16 was transferred to the hospital on 4/14/25.

Review of Resident R16's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of the clinical record indicated Resident R19 was admitted to the facility on 12/28/22.

Review of Resident R19's MDS dated 3/13/25, indicated diagnoses of atrial fibrillation (irregular heart rhythm), diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs).

Review of the clinical record indicated Resident R19 was transferred to the hospital on 1/28/25.

Review of Resident R19's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of Resident R38's clinical record indicated the resident was admitted to the facility on 8/21/13.

Review of Resident R38's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/17/25, indicated diagnoses of cancer (an uncontrolled growth and division of abnormal cells), heart failure (a progressive heart disease that affects pumping action of the heart muscles), and, diabetes.

Review of the clinical record indicated Resident R38 was transferred to the hospital on 2/15/25.

Review of Resident R38's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

During an interview on 4/24/25, at 2:46 p.m. the Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for three of five residents as required.

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



 Plan of Correction - To be completed: 06/04/2025

Resident R16 returned to facility on 04/27/2025.
Resident R19 returned to the facility on 03/30/2025.
Resident R38 returned to the facility 03/07/2025.

Licensed nursing staff members will receive education by the registered nurse instructor/designee to provide appropriate documentation for resident hospital transfers that will include bed hold policy, POLST, face sheet and Continuity of Care document.

Random audits of 5 residents transferred to another facility will be completed weekly x4 weeks and monthly x 2 months to ensure appropriate documentation was sent with the resident upon transfer

Audit results will be reported to the QAPI committee for review

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:

Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to accommodate the call bell needs for one of five residents (Resident R88).

Findings include:

Review of the clinical record indicated Resident R88 was admitted to the facility on 10/24/23.

Review of Resident R88's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/13/25, indicated diagnoses of hemiplegia (paralysis on one side of the body), anxiety, and constipation.

During an observation on 4/21/25, at 12:18 p.m. Resident R88's call bell was observed on the floor under the resident's bed.

During an interview on 4/21/25, at 12:19 p.m. Licensed Practical Nurse Employee E2 confirmed Resident R88's call bell was not accessible and unavailable for use to the resident and that the facility failed to accommodate Resident R88's call bell needs.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 211.10(d) Resident care policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.



 Plan of Correction - To be completed: 06/04/2025

Resident R88's call bell was cleaned and provided

Current residents in the facility were audited to ensure call bells were checked throughout for accessibility.

Nursing staff members will receive education from the Registered Nurse Instructor/designee to have call bells accessible to residents.

Random audits of 5 resident call bells will be audited for accessibility weekly x4 weeks and monthly x2 months

Audit results will be reported to the QAPI committee for review

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 a review of facility policy, Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS - a periodic assessment of care needs) assessments accurately reflected the resident's status for two of six residents (Residents R51 and R113).

Findings include:

Review of facility policy "MDS 3.0 Completion, Maintenance, and Submission" dated 1/16/25, indicated all disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment.

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions:
- Section O: Special Treatments, Procedures, and Programs - Question O0110C1, Oxygen therapy: Code continuous or intermittent oxygen administered via mask, cannula, etc., delivered to a resident to relieve hypoxia in this item. Code oxygen used in Bi-level Positive Airway Pressure/Continuous Positive Airway Pressure (BiPAP/CPAP) here. Do not code hyperbaric oxygen for wound therapy in this item. This item may be coded if the resident places or removes their own oxygen mask, cannula. O0110C3, Intermittent: check if oxygen therapy was intermittent (i.e., not delivered continuously for at least 14 hours per day).
- Section O: Special Treatments, Procedures, and Programs - Question O0110G1, Non-invasive Mechanical Ventilator: Code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support their own spontaneous respiration by providing enough pressure when the individual inhales to keep their airways open, unlike ventilators that "breathe" for the individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here. This item may be coded if the resident places or removes their own BiPAP/CPAP mask/device. O0110G3, CPAP: check if the non-invasive mechanical ventilator support was CPAP.
-Section O Special Treatments, Procedures, and Programs - Question O0110K1, Hospice Care: Code residents identified as being in a hospice program for terminally ill persons where an array of services is provided for the management of terminal illness and related conditions.

Review of the clinical record indicated Resident R51 was admitted to the facility on 12/11/18.

Review of Resident R51's MDS dated 3/27/25, indicated diagnoses of high blood pressure, Chronic Obstructive Pulmonary Disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions).

Review of a physician order dated 7/12/24, indicated to administer oxygen up to 6 liters via nasal cannula as needed to maintain oxygen saturation levels between 88% to 92%.

Review of a physician order dated 2/27/25, indicated Auto CPAP 15/6 pressure. Assist resident with donning (applying) every night. Fill humidifier chamber with distilled water. Check mask seal for air leaks, adjust headgear straps as needed. Apply chin strap. Resident to be assisted to lateral sleeping position with wedge pillow.

Review of Resident R51's March 2025 "Vitals - O2 (Oxygen) Saturation" documentation revealed the resident received intermittent oxygen therapy for ten days of the 14-day look-back period.

Review of Resident R51's March 2025 Treatment Administration Record revealed documentation to indicate the resident used his CPAP machine twice within the 14-day look-back period.

Review of Resident R51's quarterly MDS dated 3/27/25, Section O - Special Treatments, Procedures, and Programs: Question O0110C1 was not checked to indicate the resident received oxygen therapy during the 14-day look-back period. Question O0110G1 was not checked to indicate the resident received non-invasive mechanical ventilator therapy during the 14 day look-back period.

During an interview on 4/23/25, at 12:15 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E6 confirmed Resident R51's quarterly MDS dated 3/27/25, was coded incorrectly and should have been coded to capture the resident's oxygen and non-invasive mechanical ventilator therapy.

Review of clinical record indicated that Resident R113 was admitted to the facility on 3/10/21.

Review of Resident R113's MDS dated 1/9/25, indicated diagnosis of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and bipolar disorder (a mental condition marked by alternating periods of elation and depression). Section O - Special Treatments, Procedures, and Programs: Question O0110K1 was checked to indicate that resident received hospice care while a resident.

Review of Resident R113's clinical record failed to reveal that resident was ordered hospice services.

During an interview on 4/23/25, at 11:47 a.m. RNAC Employee E6 confirmed that resident R113 has never received hospice services and that the MDS dated 1/9/25, was marked incorrectly.

28 Pa. Code 201.14(a)(c) Responsibility of licensee.
28 Pa. Code 211.5(f) Clinical records.
28 Pa. Code 211.12(c)(d)(5) Nursing services.



 Plan of Correction - To be completed: 06/04/2025

Resident R51 MDS dated 03/27/2025 Section O has been modified to capture oxygen and non-invasive mechanical ventilator therapy.

Resident 113's MDS dated 01/09/2025 Section O has been modified to remove the indication of Hospice care

Other residents Minimum Data Set for Section O were reviewed for Oxygen and non-invasive mechanical ventilator therapy for accuracy

Other residents who are receiving hospice services MDS Section O reviewed for accuracy

Registered Nurse Assessment coordinator will receive education on facility Minimum Data Set policy from the Registered Nurse Instructor/designee.

Random Minimum Data Set audits For Section O of 5 residents will be completed weekly X4 weeks and monthly X2 months for accuracy

Audit results will be reported to the QAPI committee for review

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

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan to meet care needs for two of eight residents (Residents R40 and R89).

Findings include:

Review of facility policy "Comprehensive Care Plans" last reviewed on 1/16/25, indicated that facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment.

Review of the clinical record indicated Resident R40 was admitted to the facility on 9/23/24.

Review of Resident R40's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/3/25, indicated diagnoses of anemia (low levels of iron in the blood), high blood pressure, and Parkinson's Disease (neuromuscular disorder causing tremors and difficulty walking).

Review of a physician order dated 9/23/24, indicated to administer mirtazapine (an antidepressant) 7.5 mg (milligrams) by mouth at bedtime.

Review of a physician order dated 9/23/24, indicated to administer ramelteon (a sedative/hypnotic) 8 mg by mouth at bedtime.

Review of a physician order dated 2/5/25, indicated to administer Trintellix (an antidepressant) 20 mg by mouth every morning.

Review of Resident R40's current care plan failed to include the development of goals and interventions related to the resident's antidepressant and sedative/hypnotic medication therapy.

During an interview on 4/24/25, at 10:51 a.m. the Director of Nursing confirmed Resident R40's care plan did not reflect the use of antidepressant and sedative/hypnotic medications, and that the facility failed to develop and implement a comprehensive care plan to meet care needs for Resident R40 as required.

Review of Resident R89's clinical record indicated the resident was admitted to the facility on 7/3/19.

Review of Resident R89's MDS dated 3/6/25, indicated diagnoses of difficulty swallowing, vitamin deficiency, and Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior).

Review of Resident R89's physician order dated 4/30/20, indicated to apply bilateral lower knee TED hose (compression stockings designed to prevent blood clots, and swelling in the legs) daily at 2:30 p.m. for PVD (peripheral vascular disease, a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs).

Review of Resident R89's current care plan failed to include use of TED hose.

During an interview on 4/23/25, at 11:42 a.m. Registered Nurse Assessment Coordinator Employee E6 confirmed Resident R89's care plan did not reflect the use of TED hose, and that the facility failed to develop and implement a comprehensive care plan to meet care needs for Resident R89 as required.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1)(e)(1) Management.
28 Pa. Code: 211.12(d)(1)(3)(5) Nursing Services.



 Plan of Correction - To be completed: 06/04/2025

Resident R40 care plan was reviewed and updated to include antidepressants and sedative/hypnotic medication therapy.

Resident R89 care plan was reviewed and remains appropriate as TED hose order was discontinued on 04/24/2025.

Residents prescribed antidepressants and sedative/hypnotics will be reviewed for appropriate care plans.

Residents prescribed TED hose will be reviewed for appropriate care plans.

Registered Nurse Assessment Coordinator and Social Services will receive education on facility care plan policy from the Registered Nurse Instructor/designee.

Random Care plans audits on 10 residents will be completed weekly x4 weeks and monthly x 2 months for accuracy

Audit results will be reported to the QAPI committee for review

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 facility policy, clinical record review and interviews with staff, it was determined that the facility failed to revise the comprehensive care plan to reflect resident's current needs for three of six residents (Residents R29, R85, and R88).

Findings include:

Review of facility policy "Comprehensive Care Plans (Nursing Care)" dated 1/16/25, indicated the care plan will describe, at a minimum, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Review of the admission record indicated Resident R29 admitted to the facility on 6/26/24.

Review of Resident R29's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/20/25, indicated diagnoses of end stage renal disease (kidneys cease to function on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), hypertension (the force of the blood against the artery walls is too high), and diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).

Review of Resident R29's physician order dated 6/26/24, indicated sulfamethoxazole-trimethoprim (antibiotic) tablet; 400-80 milligrams twice daily for bacteremia (infection of the blood).

Review of Resident R29's current care plan on 4/24/25, failed to include interventions, goals or management of the long-term antibiotic or bacteremia.

Review of the admission record indicated Resident R85 admitted to the facility on 9/29/22.

Review of Resident R85's MDS dated 1/30/25, indicated diagnoses of dementia (a general term for loss of memory, language, problem solving and other thinking abilities that are severe enough to interfere with daily life), atrial fibrillation (irregular heart rhythm), and pain.

Review of Resident R85's physician order dated 7/25/24, indicated check resident wander guard (a bracelet that alerts staff if a resident attempts to go beyond a supervised area) every shift for placement and functionality every night shift.

Review of Resident R85's current care plan on 4/24/25, indicated the wander guard ordered 7/25/24, was not care planned timely. The care plan intervention was not initiated until 11/7/24.

Interview on 4/23/25, at 12:01 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E6 confirmed Resident R29 and Resident R85's care plans were not revised to reflect the resident's current status as required.

Review of the clinical record indicated Resident R88 was admitted to the facility on 10/24/23.

Review of Resident R88's MDS dated 3/13/25, indicated diagnoses of hemiplegia (paralysis on one side of the body), anxiety, and constipation.

Review of a physician order dated 4/11/25, indicated to administer Glucerna 1.5 (a type of tube feeding formula) at 40 mL (milliliters)/hour via gastric tube (a tube surgically inserted via the abdomen into the stomach to provide nutrition).

Review of Resident R88's care plan dated 6/4/24, revealed an intervention to administer Glucerna 1.5 at 35mL/hour via gastric tube continuously.

During an interview on 4/23/25, at 2:59 p.m. Registered Dietitian Employee E7 confirmed that the facility failed to revise Resident R88's care plan to reflect the resident's current status as required.



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




 Plan of Correction - To be completed: 06/04/2025

Resident R29 care plan was reviewed and updated to reflect current antibiotic usage with appropriate goals and interventions.

Resident R85 care plan remains appropriate as it currently lists a wanderguard as an intervention.

Resident R88 care plan was reviewed and updated for accuracy for enteral feeding.

Residents who are currently prescribed long-term antibiotics will be reviewed for appropriate care plan goals and interventions.

Residents who are currently prescribed a wandgerguard will be reviewed for appropriate care plan goals and interventions.

Residents who are currently prescribed enteral feedings will be reviewed for care plan accuracy.

Registered Nurse Assessment Coordinators, Infection Preventionist and Registered Dietitian will receive education on facility care plan policy from the Registered Nurse Instructor/designee

Random Care plans audits on 10 residents will be completed weekly x4 weeks and monthly X2 months for accuracy

Audit results will be reported to the QAPI committee for review

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 the review of facility job descriptions, clinical records, and staff interviews, it was determined that the facility failed to follow standards of professional practice for two of five residents (Residents R21 and R104).

Findings include:

Review of the facility job description "Registered Nurse (RN)" indicated the RN is to record daily care performed for the residents on the appropriate forms and the approved electronic medical record and establish and maintain effective communication with resident, family, and staff.

Review of the clinical record indicated Resident R21 was admitted to the facility on 3/5/18.

Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/6/25, indicated diagnoses of constipation, hypocalcemia (low levels of calcium in the blood), and Vitamin D deficiency.

Review of a progress note dated 4/6/25, completed by RN Employee E16 stated, "Resident continues to have menial tasks for staff that she requests one at a time. She first had RN go to her room on her way back in her wheelchair. Then, 2 minutes after RN left her room, she rang the call light. Resident seems to be anxious and incessantly wants staff in her room. In addition to the call bell, resident calls the nurses station from her phone. She flags down staff as they are walking down the hall near her. Her request are for the staff to take whatever food as a snack, she wants to talk/tell stories, she wants pulled up (even though she is a good foot and a half from the bottom of the bed and would hit her head if she were laying down and not sitting up), then she complains about her brief after she is pulled up (staff will continuously fix her location in the bed and then her brief (when one is fixed, the other bothers her and it is a continuous cycle). Resident just continuously has small requests, one at a time, continuously calling staff, or hunting them down. Resident continuously asked to make all needs known at one time."

Review of a progress note dated 4/19/25, completed by RN Employee E17 stated, "Resident continues to seek staff assistance/attention each time she sees someone. If resident sees someone near the door, walk by, or hears a voice, she will yell for them repeatedly. When staff acknowledge that they will be over when they are finished assisting the resident they are currently with, she acts like she does not hear it and continues to yell. However, she "can hear" fine other times. Then if another staff member is seen or heard, she continues to yell for them. All needs are met each time. She is fed, has a variety of drinks, is comfortable, clean and dry. She asks for multiple tasks to be completed at the same time. She will wait right beside the medication cart, resident, phone, or nurse's station while nursing is assisting another resident or on the phone and obsessively find a reason for attention. Most of the time, it is a request that could have waited until it was her turn again. She continues to monopolize each staff members time to the extent of her ability to do so."

Review of the clinical record indicated Resident R104 was admitted to the facility on 11/28/23.

Review of Resident R104's MDS dated 2/13/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood).

Review of a progress note dated 4/21/25, completed by RN Employee E17 stated, "Resident has excessively rang the call bell this morning. Each time staff enter, he whines with something he wants done. Multiple staff have assisted resident and asked if there is anything else they can do prior to leaving the room. Resident states no and then would ring the call bell very soon again. Resident is Clean and dry, he has been fed and provided with beverages, he has been repositioned, he had PRN (as needed) analgesics this AM."

During an interview on 4/25/25, at 9:35 a.m. the Director of Nursing confirmed that the facility failed to follow standards of professional practice for Residents R21 and R104.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.
28 Pa. Code: 201.29(a) Resident rights.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.



 Plan of Correction - To be completed: 06/04/2025

Resident R21's progress note was reviewed with involved staff member from the Facility Nurse Administrator.

Resident R104's progress note was reviewed with involved staff member from the Facility Nurse Administrator.

The involved staff member received documentation education regarding progress notes related to standards of professional practice for appropriate communication from the Facility Nurse Administrator/designee.

Licensed nursing staff will receive education for appropriate and professional documentation from the Registered Nurse Instructor/designee

Random audits of progress notes on 5 residents will be reviewed weekly x 4 weeks and monthly x2 months for standards of professional practice

Audit results will be reported to the QAPI committee for review

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 review of facility policy, clinical records, observations, and interviews with staff, it was determined that the facility failed to make certain that residents received proper treatment for pressure ulcers for two of four residents (Residents R21 and R88) and failed to make certain that residents received the necessary services to prevent pressure ulcers/wounds from developing for one of four residents (Resident R133).

Findings include:

Review of the facility policy "Management of Pressure Injuries" dated 1/16/25, indicated the facility will use a standardized plan for defining, assessing, documenting, and implementing strategies for the prevention and treatment of pressure injuries on all residents. Braden Scale will be the instrument used to determine the potential or actual risk for pressure ulcers. Residents who score between 15-18 are at risk. Utilization of pressure relieving devices, including special mattresses, elbow, and heel protectors may be used. Residents with pressure ulcers shall receive dressing changes based upon stage and severity of the wounds.

Review of facility policy "Management of Pressure Injuries" dated 1/16/25, indicated residents with pressure ulcers shall receive dressing changes based upon stage and severity of the wounds.

Review of the facility "Licensed Practical Nurse (LPN)" job description indicated the LPN will administer medications and treatments timely and accurately as ordered by a physician.

Review of the clinical record indicated Resident R21 was admitted to the facility on 3/5/18.

Review of Resident R21's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/6/25, indicated diagnoses of constipation, hypocalcemia (low levels of calcium in the blood), and Vitamin D deficiency.

Review of a physician order dated 1/2/25, indicated to cleanse sacral (base of spinal column) wound with 1/4 strength Dakin's solution (an antiseptic cleanser) - lightly packing undermining and tunneling with Calcium Alginate AG (a highly absorbent dressing). Cover wound bed with collagen (used to promote new tissue growth). Cover with foam dressing every other day and PRN (as needed).

Review of Resident R21's March 2025 Medication Administration Record (MAR) indicated the treatment was not documented as completed on the following shift:
- 3/30/25 6:30 a.m. to 2:30 a.m., the documented reason was, "done by night staff"

Review of Resident R21's clinical record failed to include additional documentation that the treatment was performed on 3/30/25.

Review of a physician order dated 3/31/25, indicated to wash coccyx (tailbone) with soap/water. Apply prisma (a type of dressing that promotes wound healing while preventing infection) to wound base with exufiber (a highly absorbent dressing) to surrounding tunneling and remaining wound, cover with foam dressing QOD (every other day) and PRN.

Review of Resident R21's April 2025 MAR indicated the treatment was not documented as completed on the following shift:
- 4/20/25 2:30 p.m. to 10:30 p.m., the documented reason was, "done 4/19"

Review of Resident R21's clinical record failed to include additional documentation that the treatment was performed on 4/19/25.

Review of the clinical record indicated Resident R88 was admitted to the facility on 10/24/23.

Review of Resident R88's MDS dated 3/13/25, indicated diagnoses of hemiplegia (paralysis on one side of the body), anxiety, and constipation.

Review of a physician order dated 11/7/23, indicated to apply Dakin's 0.25% soaked gauze packed to sacral wound daily. Cover with foam dressing.

Review of Resident R88's April 2025 MAR indicated the treatment was not documented as completed on the following shifts:
- 4/18/25, 6:30 a.m. to 2:30 p.m., the documented reason was, "prior shift"
- 4/19/25, 6:30 a.m. to 2:30 p.m., the documented reason was, "previous shift did"

Review of Resident R88's clinical record failed to include additional documentation that the treatment was performed on 4/18/25, and 4/19/25.

During an interview on 4/24/25, at 2:45 p.m. the Director of Nursing confirmed that the facility failed to make certain that Residents R21 and R88 received proper treatment for pressure ulcers as required.

Review of Resident R133's clinical record indicated the resident was admitted to the facility on 1/8/25.

Review of Resident R133's MDS dated 4/3/25, indicated diagnoses of high blood pressure, depression, and cancer (an uncontrolled growth and division of abnormal cells). MDS Section GG Functional Abilities, Line H labeled- putting on/taking off footwear is coded as a "1", dependent, helper does all of the effort.

Review of Resident R133's Braden scale dated 1/8/25, revealed resident scored an 18, high risk for pressure injury.

Review of Resident R133's physician order dated 1/8/25, indicated bilateral Prevalon boots (padded boot that Velcro's around the foot to stay in place) while in bed.

Review of Resident R133's care plan dated 1/9/25, indicated resident is to wear bilateral Prevalon boots while in bed due to impaired mobility to prevent pressure injury/impaired skin integrity.

During an observation on 4/21/25, at 10:50 a.m. resident was lying in bed and failed to have Prevalon boots on.

During an interview on 4/21/25, at 10:55 a.m. Registered Nurse (RN) Employee E8 confirmed that Resident R133's Prevalon boots were sitting at bedside and resident failed to have them on per physician orders. RN Employee E8 confirmed that the failed to make certain that Resident R133 received the necessary services to prevent pressure ulcers/wounds from developing.

During an observation on 4/25/25, at 9:25 a.m. resident was lying in bed and failed to have Prevalon boots on.

During an interview on 4/25/25, at 9:31 a.m. LPN Employee E11 confirmed that Resident R133's Prevalon boots were sitting near the window and resident failed to have them on per physician orders. LPN Employee E11 confirmed that facility failed to make certain that Resident R133 received the necessary services to prevent pressure ulcers/wounds from developing.


28 Pa. Code 201.18 (b)(1) Management.
28 Pa. Code 211.10(c)(d) Resident Care Policies.
28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services.



 Plan of Correction - To be completed: 06/04/2025

Resident R21 sacral wound dressing was assessed, and a dressing change was completed by the facility Wound Care Nurse on 4/29/2025.

Resident R88 sacral wound dressing was assessed, and a dressing change was completed by the facility Wound Care Nurse on 4/21/2025.

Residents with pressure injuries were assessed by the facility wound care nurse for appropriate treatments.

Resident R133 Prevalon boots were applied.

Residents ordered Prevalon boots were reviewed for continued appropriateness and wear schedule.

Licensed nursing staff will receive education on facility policy of Management of Pressure Ulcers from the Registered Nurse Instructor/designee.

Random audits of 5 residents with pressure ulcers will occur weekly x 4 weeks and monthly x 2 months for appropriate treatments/documentation

Audit results will be reported to the QAPI committee for review

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

Based on review of facility policy and clinical record and staff interview it was determined that the facility failed to make certain consistent dialysis communication was maintained for two of three residents. (Residents R33 and R104).

Findings include:

Review of the facility policy "Pre and Post Dialysis" dated 1/16/25, indicated prior to departing the unit for transfer to dialysis (the clinical purification of blood by dialysis as a substitute for the normal function of the kidney), the licensed staff will complete the Dialysis Communication Form with each transfer to the dialysis clinic. Upon return to the unit, the licensed staff will complete the return portion of the Dialysis Communication Form and file in the appropriate section of the chart. If no communication form is received, please call dialysis, and have one faxed to the facility.

Review of the admission record indicated Resident R33 was admitted to the facility on 3/15/17.

Review of Resident R33's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/13/25, indicated the diagnoses of renal failure (condition where the kidneys lose the ability to remove waste and balance fluids) with dialysis, stroke (damage to the brain from an interruption of blood supply), and hemiplegia (paralysis of one side of the body).

Review of the physician order dated 3/24/25, indicated that Resident R33 goes to dialysis on Monday, Wednesday and Friday.

Review of Resident R33's current care plan indicated dialysis communication sheet to be sent with resident for completion by dialysis clinic to return to facility on days treatment to include: any problems, new orders, dialysis treatment, dialysis duration, pre-weight and blood pressure, and temperature. Post treatment weight, blood pressure, temperature, any adverse effects (fever, prolonged bleeding), bleeding, and any labs performed with signature and contact information.

Review of the clinical record did not include complete communication forms for thirteen days during the period of 2/3/25, through 4/16/25. The incomplete forms were on the following dates: 2/3/25, 2/5/25, 2/7/25, 2/10/25, 2/17/25, 2/19/25, 2/28/25, 3/12/25, 3/19/25, 3/31/25, 4/11/25, 4/14/25, and 4/16/25.

Interview on 4/21/25, at 12:19 p.m. Registered Nurse (RN) Employee E15 confirmed the above dates did not include complete communication forms as required for Resident R33.

Review of the clinical record indicated Resident R104 was admitted to the facility on 11/28/23.

Review of Resident R104's MDS dated 2/13/25, indicated diagnoses of high blood pressure, hyperlipidemia (high levels of fat in the blood), and End-Stage Renal Disease (ESRD, an inability of the kidneys to filter the blood).

Review of a physician order dated 3/24/25, indicated the resident receives dialysis treatment at an outside facility every Monday, Wednesday, and Friday.

Review of Resident R104's care plan dated 11/28/23, indicated to prepare Dialysis Communication Form for daylight shift by completing the ENTIRE first page of the form. Special instructions: pass form to daylight nurse at change of shift.

Review of Resident R104's clinical record did not include complete communication forms for three days during the period of 3/1/25, through 4/22/25. The incomplete forms were on the following dates: 4/4/25, 4/7/25, and 4/16/25.

During an interview on 4/22/25, at 10:47 a.m. Licensed Practical Nurse Employee E3 confirmed the above dates did not include complete dialysis communication forms and that the facility failed to make certain consistent dialysis communication was maintained for Resident R104.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code 211.5(f) Medical records.
28 Pa. Code: 211.12(c)(d)(1)(3)(5) Nursing services.



 Plan of Correction - To be completed: 06/04/2025

Resident R33's Facilty Assistant Director of Nursing communicated with Davita Dialysis Facility Administrator on 4/28/2025 on importance of returning completed dialysis communication forms.

Resident R104's Facility Assistant Director of Nursing communicated with UDVA Dialysis clinic on the importance of returning completed dialysis communication forms.

Licensed nursing staff will be educated on policy for Pre and Post Dialysis from the Registered Nurse Instructor/desginee.

Current facility residents receiving dialysis service will be audited weekly x 4 weeks and monthly x 2 months to ensure dialysis forms are fully completed

Audit results will be reported to the QAPI committee for review

483.25(m) REQUIREMENT Trauma Informed Care: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(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
Observations:

Based on review of facility policy, resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of four residents (Residents R7 and R51).

Findings include:

Review of facility policy "Culturally Competent, Trauma Informed Care" dated 1/16/25, indicated the purpose of this protocol is to provide guidance to the facility to guide staff in providing appropriate, culturally competent care to residents who have experienced a trauma and to safeguard re-traumatization by employing supportive services related to minimizing triggers. The facility will assess each resident for a history of trauma and cultural preferences, upon admission, annually and with significant change. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, discussing cultural needs and social history. The resident's Plan of Care will be implemented with individualized interventions that include trigger specific interventions addressing ways to decrease re-traumatization, as well as identifying ways to mitigate or decrease the effect of the trigger on the resident. In situations where a trauma survivor is reluctant to share their history, the facility will try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.

Review of the clinical record indicated Resident R7 was admitted to the facility on 9/12/24.

Review of Resident R7's Minimum Data Set (MDS - a periodic review of a care needs) dated 3/6/25, indicated diagnoses of hemiplegia (paralysis on one side of the body), Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event and may have triggers that can bring back memories of trauma accompanied by intense emotional and physical reactions), and pain in left hip.

Review of Resident R7's care plan dated 12/6/24, indicated the resident has an increased risk of behavior and emotional distress related to post traumatic stress disorder stemming from an automobile accident and assault/shooting by a neighbor.

Review of Resident R7's PTSD assessment dated 12/6/24, indicated the resident's reported triggers were loud noises.

Review of a progress note dated 12/6/24, completed by Social Work (SW) Employee E14 stated, "SW completed PCL-5 Assessment for PTSD with resident in his room. He has a current score of 58, and reports that the PTSD stemmed from an automobile accident and an assault by a neighbor in which he was attacked and shot. His score does support his PTSD diagnosis and indicates ongoing symptoms of that condition. SW will review his PTSD care plan to be sure it is accurate and takes appropriate steps to avoid resident's triggers. A copy of the PCL-5 completed today will be stored in resident's clinical documents."

During an interview on 4/24/25, at 11:32 a.m. Social Work Director Employee E4 stated PTSD assessments are completed within 30 days of admission.

During an interview on 4/24/25, at 11:32 a.m. Social Work Director Employee E4 confirmed Resident R7 should have had a PTSD assessment performed and care plan developed within 30 days of the resident's admission to the facility on 9/12/24, and that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for Resident R7.


Review of the clinical record indicated Resident R51 was admitted to the facility on 12/11/18.

Review of Resident R51's MDS dated 3/27/25, indicated diagnoses of high blood pressure, Chronic Obstructive Pulmonary Disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness), and Post Traumatic Stress Disorder.

Review of Resident R51's care plan dated 4/25/24, indicated the resident has an increased risk for of behavioral and emotional distress related to post traumatic stress disorder due to experiences in combat during Vietnam War. The resident's care plan failed to include identified triggers or documentation indicating the resident declined to identify triggers related to the resident's PTSD.

During an interview on 4/24/25, at 11:25 a.m. Social Work Director Employee E4 confirmed that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for Resident R51.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.



 Plan of Correction - To be completed: 06/04/2025

R 7's care plan will be amended to include loud noises as a trigger

R 51's care plan will be updated to include documentation surrounding triggers

Like residents will be reviewed to ensure trauma survivors have documentation of trauma informed care to mitigate triggers included in the care plan

Education will be completed with the social worker's by the NHA/designee on Trauma informed care

Audits will be completed weekly x4 and monthly x2 to ensure residents with trauma informed care have appropriate triggers in the resident care plan

Audit results will be reported to the QAPI committee for review

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:

Based on review of personnel records and staff interview it was determined that the facility failed to complete annual performance evaluation for one of three nurse aide (NA) personnel records (NA Employee E18).

Findings include:

Review of CFR (Code of Federal Regulations) Regular in-service education. The facility must complete a performance review of every nurse aide at least once every 12 months and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of of NA Employee E18's personnel record indicated she was hired to the facility on 5/2/22.

Review of personnel records did not include an annual performance evaluation based on the date of hire for NA Employee E18.

Interview on 4/22/25, at 1:16 p.m. Human Resource's Employee E5 confirmed that the facility failed to complete annual performance evaluation based on date of hire for NA Employee E18.

28 Pa Code: 201.14 (b) Responsibility of licensee
28 Pa Code: 201.18 (b)(1)(3) Management








 Plan of Correction - To be completed: 06/04/2025

E18 performance review was completed

Current nursing assistant employee files at the facility are being audited for current performance evaluations any outstanding evaluations will be completed

Education will be completed with the facility human resources staff members by the NHA/designee on performance evaluation requirements for nursing assistants

Audits will be completed weekly X4 weeks and monthly X2 months on completion of nursing assistant employee performance evaluations

Audit results will be reported to the QAPI committee for review

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§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)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to maintain proper infection control practices related to the care of indwelling urinary catheters (tube inserted in the bladder to drain urine) for one of three residents reviewed (Residents R107).

Findings include:

Review of facility policy "Urinary Catheter Procedures" dated 1/16/25, indicated the purpose is to promote a healthy urinary tract, promote continence, and to maintain healthy skin integrity. To achieve free flow of urine the collection bags, tubing is never to touch the floor.

Review or facility policy "Infection Control Plan" dated 1/16/25, indicated policy is to maintain a consistent, comprehensive approach to the prevention and management of infections. The goal of the program is to provide a safe and sanitary environment, decrease the risk of infection to residents, and correct problems relating to infection control practices.

Review of Resident R107's clinical record indicated the resident was admitted to the facility on 6/14/24.

Review of Resident R107's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 3/6/25, indicated diagnoses of high blood pressure, cancer (an uncontrolled growth and division of abnormal cells), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time).
Review of a physician order dated 6/14/24, indicated the resident has a foley catheter for obstructive uropathy (a blockage in the flow of urine).

During an observation on 4/21/25, at 10:50 a.m. Resident R107 was sitting in a wheelchair beside his bed watching tv and his catheter bag was lying directly on the floor beside him.

During an interview on 4/21/25, at 10:53 a.m. a.m. Registered Nurse (RN) Employee E8 confirmed Resident R107's catheter collection bag was on the floor and that the facility failed to maintain proper infection control practices related to Resident R107's indwelling urinary catheter as required.

28 Pa. code: 201.14 (a) Responsibility of licensee.
28 Pa. Code: 201.18 (b) (1) (e) (1) Management.
28 Pa. Code: 211.10 (d) Resident care policies.
28 Pa. Code: 211.12 (d) (1) (2) (5) Nursing services




 Plan of Correction - To be completed: 06/04/2025

Resident 107's foley catheter bag was repositioned to an appropriate placement

Residents with indwelling urinary catheters bags were reviewed for appropriate placement

Nursing staff educated on BVH Urinary Catheter Procedure Section F Straight Drainage Bag, sections 1a, 1b and1c from the Registered Nurse Instructor/designee

Random audits on 5 residents with indwelling urinary catheters will be audited weekly x 4 weeks and monthly x 2 months to ensure catheter bags are in an appropriate location

Audit results will be reported to the QAPI committee for review

§ 201.19(1) LICENSURE Personnel policies and procedures.:State only Deficiency.
(1) The employee's job description, educational background and employment history.

Observations:

Based on review of personnel files and staff interviews, it was determined that the facility failed to ensure that personnel records contained a copy of the employee's signed job description for two of five personnel files reviewed (Food Service Worker Employee E12 and Nurse Aide (NA) Employee E13).

Findings include:

Review of Food Service Worker Employee E12's personnel file revealed the employee was hired on 3/20/25. Review of Food Service Worker Employee E12's personnel file revealed the employee's job description was not signed until 4/22/25.

Review of NA Employee E13's personnel file revealed the employee was hired on 2/26/25. Review of NA Employee E13's personnel file revealed the employee's job description was not signed until 4/22/25.

During an interview on 4/22/25, at 1:01 p.m. Human Resource Analysis Employee E5 confirmed that the facility failed to ensure that personnel records contained a copy of the employee's signed job description for two of five personnel files reviewed as required.



 Plan of Correction - To be completed: 06/04/2025

E12 and E13 now have current job descriptions signed

Current employee files at the facility are being audited to ensure signed job descriptions are in place in the employee personnel file

Education will be completed with the facility human resources staff members by the NHA/designee on ensuring employee job descriptions are signed during employee orientation

Audits will be completed weekly X4 weeks and monthly X2 months on completion of employee signed job descriptions

Audit results will be reported to the QAPI committee for review


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