Pennsylvania Department of Health
 WILLOW GROVE POST ACUTE
Patient Care Inspection Results

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WILLOW GROVE POST ACUTE
Inspection Results For:

There are  119 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
WILLOW GROVE POST ACUTE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey, and an Abbreviated Survey in response to one complaint completed on May 16, 2025, it was determined that Willow Grove Post Acute was not in compliance with the requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.


 Plan of Correction:


483.10(g)(4)(i)-(vi) REQUIREMENT Required Notices and Contact 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.
§483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including:
(i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes -
(A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section;
(B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act.
(C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and
(D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
(ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.)
(iii) Information regarding Medicare and Medicaid eligibility and coverage;
(iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program;
(v) Contact information for the Medicaid Fraud Control Unit; and
(vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
Observations:

Based on observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency and the State Long-Term Care Ombudsman program phone number and contact information readily accessible on the two of two nursing floors. (1st Floor, and 2nd Nursing Units)

Findings include:

During an observation of First Floor nursing units on May 13, 2025 at 11:44 a.m. revealed there was no posting for the required Department of Health contact information or required postings for the State Long-Term Care Ombudsman. A tour of the lobby area revealed there was a standard size page for the contact information for the State Long-Term Ombudsman in the entry way between the two glass entry doorways.

Resident Council meeting was held on May 14, 2025, at 10:15 a.m. held on the second floor with four alert and oriented residents reported that they were not aware how to contact the State Department of Health or Ombudsman Office and have not seen any postings in the building. (R17, R58, R61, R77)

Observations during a tour with the Director of Social Services, Employee E8 of the Second Floor Nursing unit on May 14, 2025 at 11:05 a.m. revealed there were no postings for the required Department of Health or the State Long-Term Care Ombudsman.

The Nursing Home Administrator Employee E1 on May 14, 2025, at 3:06 p.m. confirmed the posting of the Ombudsman contact information was only posted in the entry way between the two glass entry doorways. There was no posting of the State Department of Health and Ombudsman contact information readily available on the Second floor. There was no Department of Health information posted in the facility.

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

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







 Plan of Correction - To be completed: 07/08/2025

- Information, and posting on contacting the State Department of Health, and the Ombudsman Office have been made available and accessible to residents on both floors.
- Residents R17, R58, R61 and R77 will be educated on how to contact the State Department of Health, and the Ombudsman Office. The Activities Director/designee will also review at the next Resident council meeting.
- Social Services Director/Designee will be educated to ensure that the Notices and information on contacting the Department of Health, and the Ombudsman Office is posted, available and accessible to residents.
- Social Services Director/designee will complete an audit weekly x4, and monthly x2 to ensure that the contact information for the Department of Health and Ombudsman remains posted and accessible to residents.
- Results of the audit will be presented to the QAPI committee at the subsequent meeting.

483.95(g)(1)-(4) REQUIREMENT Required In-Service Training for Nurse Aides: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.
§483.95(g) Required in-service training for nurse aides.
In-service training must-

§483.95(g)(1) Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year.

§483.95(g)(2) Include dementia management training and resident abuse prevention training.

§483.95(g)(3) Address areas of weakness as determined in nurse aides' performance reviews and facility assessment at § 483.71 and may address the special needs of residents as determined by the facility staff.

§483.95(g)(4) For nurse aides providing services to individuals with cognitive impairments, also address the care of the cognitively impaired.
Observations:

Based on reviews of staff training and competency sets for nursing assistants, reviews of the facility assessment and interviews with staff, it was determined that, the facility failed to ensure that nursing assistants retained a required minimum of 12 hours of nursing training annually for two of four nurse aides record reviewed. (Employees E24 and E25).

Findings include:

A review of the facility assessment revealed that the residents at this facility were at risk for falls, required increased help with activities of daily living, had behavioral health needs, dementia and memory care needs, were prescribed psychoactive medications, had skin integrity issues, required tube feedings and pressure ulcer care.

Employee E24, nursing assistant was hired on March 12, 2024. Annual training and competencies based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techiques, emergency preparedness, resident rights, cultural competency) were not documented and available for review for this nursing assistant.

Employee E25, nursing assistant was hired on September 1, 2004. Annual training and competencies based on the needs of the residents (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techiques, emergency preparedness, resident rights, cultural competency) were not documented and available for review for this nursing assistant.

Interview with the designated nurse trainer/instructor/facilitator, Employee E6, at 9:00 a.m., on May 16, 2025 confirmed that the necessary trainings and competency sets for (dementia care of the cognitively impaired, abuse prevention, accident prevention, restorative nursing techiques, emergency preparedness, resident rights, cultural competency) were not documented or available for review for nursing staff (Employees E5 and E27) that were selected for review.


28 PA. Code 201.20(a)(1)(2)(5)(6) Staff development

28 PA. Code 201.14(a) Responsibility of licensee

28 PA. Code 201.19(1)(3)(7) Personnel policies and procedures






 Plan of Correction - To be completed: 07/08/2025

- Employees 24 and 25 will receive annually required nurse aid training
- An initial audit of all current Nurse Aides will be competed to ensure that there required 12hrs training is up to date
- Random audits will be completed weekly x 4, then monthly x 2 to ensure that nurse aids are up to date on required 12hrs training Results of the audit will be presented to the QAPI committee at the subsequent meeting.

483.95(c)(1)-(3) REQUIREMENT Abuse, Neglect, and Exploitation Training: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.
§483.95(c) Abuse, neglect, and exploitation.
In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on-

§483.95(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12.

§483.95(c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property

§483.95(c)(3) Dementia management and resident abuse prevention.
Observations:

Based on review of facility policy, review of employee files, and staff interviews, it was determined that the facility failed to provide training upon hire on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and prevention of resident abuse for thirteen of forty employees reviewed (E11, E12, E15, E16, E17, E18, E19, E20, E21, E31, E32, E33, E34)

Findings Include:

Review of facility policy titled, "Abuse, Neglect, Exploitation and Misappropriation Prevention Program" revised April 2021 states, "Policy Interpretation and Implementation- The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: a. facility staff; b. other residents; c. consultants; d. volunteers; e. staff from other agencies; f. family members; g. legal representatives; h. friends; i. visitors; and/or j. any other individual."

Review of the Staff Development employee's job description revealed under Administrative Functions, "Ensure that all personnel attend and participate in annual Center in-service training programs (e.g... Abuse Prevention...)."

Employee training records were requested for Employee E11, E12, E22, E23 on May 15, 2025 at 1:00 p.m. from the Nursing Home Administrator Employee E1 and Regional Director of Nursing Employee E3.

A second request was made for Employees E11, E12, E22, and E23 on May 16, 2025. Employees E11, E12, E22, and E23 records were reviewed and none of them had abuse trainings records.

Interview held with Scheduling/ Payroll staff, Employee E7 was asked to provided abuse training records and she stated, "that would be the training department Staff Development, Employee E6".

Interview with Staff Development Employee E6 on May 16, 2025 at 11:26 a.m. "I would be responsible for making sure staff complete the trainings". Employee E6 was asked to pull up proof of Abuse training for Employees E22, E11, E12, and E23. Employee E6 pulled up each employee's online professional trainings individually and stated that there was "nothing" when each employee was pulled up individually and spelling of names were checked. When asked who was responsible for ensuring staff are training on abuse, neglect, and exploitation she said, "I am but a lot of these people I don't see or I haven't seen".

An additional request for abuse training records for all Employees hired since January 1, 2025 revealed serval staff not having documented evidence that the facility provided training for nine employees (E11, E12, E15, E16, E17, E18, E19, E20) on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and prevention of resident abuse evidence that the facility provided training on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and prevention of resident abuse.


Review of facility training records revealed Central Supply, Employee E11 was hired March 4, 2025 and had no evidence of abuse training.
Review of facility training records revealed Maintenance Employee E12 was hired on February 3, 2025 and had no evidence of abuse training.
Review of facility training records revealed Licensed Nurse Employee E15 was hired on April 22, 2025 and had no evidence of abuse training.
Review of facility training records revealed Licensed Nurse Employee E16 was hired on April 16, 2025 and had no evidence of abuse training.
Review of facility training records revealed Licensed Nurse Employee E17 was hired on April 14, 2025 and had no evidence of abuse training.
Review of facility training records revealed Nurse Aide Employee E18 was hired on March 11, 2025 and had no evidence of abuse training.
Review of facility training records revealed Nurse Aide Employee E19 was hired on March 11, 2025 and had no evidence of abuse training.
Review of facility training records revealed Nurse Aide Employee E20 was hired on March 4, 2025 and had no evidence of abuse training.
Review of facility training records revealed Licensed Nurse E21 was hired on February 25, 2025 and had no evidence of abuse training.

Further review of the new hire list since January 2025 revealed the following staff hired and not trained upon hire on a policy that includes abuse, neglect, exploitation, and misappropriation:

Licensed Nurse Employee E31 was hired on April 8, 2025 and did not receive training until April 25, 2025.
Nurse Aide Employee E32 was hired on March 18, 2025 and did not receive training until April 30, 2025.
Nurse Aide Employee E33 was hired on March 4, 2025 and did not receive training until April 14, 2025.
Maintenance Employee E12 was hired on February 2, 2025 and did not receive training until April 8, 2025.
Licensed Nurse Employee E34 was hired on January 28, 2025 and did not receive training until April 2, 2025.

Facility was provided additional time to submit documentation related to abuse training for the above employees, however no documentation was provided.

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









 Plan of Correction - To be completed: 07/08/2025

- Employees 11, 12, 15, 16, 17, 18, 19, 20, 21 22, 23 received training on abuse, neglect and exploitation
- An audit was completed of All current employees to ensure that they received training on abuse, neglect and exploitation.
- Director of Nursing / designee with educate the Staff development nurse on the facility policy on new hire orientation process.
- Audits will be completed on all newly hired staff weekly x 4, then monthly x 2 to ensure newly hired employees have received time training on abuse, neglect and exploitation. Results of the audit will be presented to the QAPI committee at the subsequent meeting.

483.35(e)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
§483.35(e)(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 facility provided documentation and interview with staff, it was determined that facility did not ensure annual performance evaluations were completed for four of four nurse aides reviewed (Employees E24, E25 E26, and E27)

Findings include:

On May 14, 2025, annual performance reviews were requested from Staff Development, Employee E6 for Employees E24, E25, E26, E27.

The facility did not provide the annual performance reviews requested for Employees E24, E25, E26, and E27 on May 16, 2025.

Interview on May 16, 2025 at 11:26 a.m. with Staff Development, Employee E6 revealed that the facility had not completed any performance reviews for any staff for the current year (2025). Employee E6 stated that there were no record from the past year (2024), including Employees E24, E25, E26 and E27. Employee E6 stated that "the old company took all of those records." When asked if the Staff Development, Employee E6 had completed any performance evaluations for the year of 2025, Employee E6 stated, "No, they are not due till June so they told me to hold off on completing them."

Nurse Aide Employee E24 was hired on May 12, 2024 and the facility was not able to provide a yearly review to show for the year of 2024 or 2025.

Nurse Aide Employee E25 was hired on September 1, 2004 and the facility was not able to provide a yearly review to show for the year of 2024 or 2025.

Licensed Nurse Employee E26 was hired on September 8, 2016 and the facility was not able to provide a yearly review to show for the year of 2024 or 2025.

Licensed Nurse Employee E27 was hired on October 8, 2015 and the facility was not able to provide a yearly review to show for the year of 2024 or 2025.

28 Pa Code 201.19(2) Personnel Policies and Procedures





 Plan of Correction - To be completed: 07/08/2025

- Facility could not retroactively correct performance evaluations for current Nurse Aides prior to Year 2025.
- Performance review for employees E24, E25, E26 and E27 will be completed on 7/8/2025 if they are still employed.
- Staff Development/designee will conduct an initial audit of all current Nurse Aides to ensure that facility is in compliance with performance evaluations for Nurse Aides hired within the previous year.
- Staff Development/designee will be educated to ensure continuing competence for Nurse Aides as required per the regulation.
- Staff Development will conduct an audit weekly x4, then monthly x2 to ensure that facility is in compliance with annual performance reviews for Nurse Aides.
- Results of the audit will be presented to the QAPI committee at the subsequent meeting.

483.35(a)(3)(4)(d) REQUIREMENT Competent Nursing Staff: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.
§483.35 Nursing Services

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(d) Proficiency of nurse aides.

The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:

Based on reviews of the facility assessment, staff training and competency skill sets to provide care and services to assure residents' safety and ensure that each resident attained or maintained their highest practicable well-being, it was determined that for two of two licensed nursing staff reviewed, the facility failed to have records of training and competencies available for review. (Employees E5 and E27)

Findings include:

A review of the facility assessment indicated that the residents at this facility were at risk for falls, required increased help with activities of daily living, had behavioral health needs, dementia and memory care needs, were prescribed psychoactive medications, had skin integrity issues, required tube feedings and pressure ulcer care.

Employee E26, a registered nurse was hired on September 8, 2016. There was no annual training and competencies available for review for the resident care areas of medication administration, tube feeding administration and care, wound care assessment, monitoring and treatment and safe transfers during care.

Employee E27, a registered nurse was hired on October 8, 2015. There was no annual training and competencies available for review for the resident care areas of medication administration, tube feeding administration and care, wound care assessment, monitoring and treatment and safe transfers during care.

Interview with the designated nurse trainer/instructor/facilitator Employee E6, at 9:00 a.m., on May 16, 2025 confirmed that these necessary trainings and competency sets were not documented or available for review for nursing staff (Employees E5 and E27) selected for review.


28 PA. Code 201.20(a)(1)(2)(5)(6) Staff development

28 PA. Code 201.14(a) Responsibility of licensee

28 PA. Code 201.19(1)(3)(7) Personnel policies and procedures





 Plan of Correction - To be completed: 07/08/2025

- Employees 5 & 27 had annual training and competencies completed
- An Audit was completed of all current employees to ensure Annual training and competencies are up to date . Any variances identified will be corrected
- Weekly audits x 4 then monthly x 2 will be completed for any new hires to ensure annual training and competencies are up to date
- Results of findings to be presented to QAPI

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

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

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

Based on clinical record reviews, interviews with residents and staff and reviews of policies and procedures and hospital records, it was determined that the facility failed to ensure that residents with bowel and bladder incontinence received care to maintain, restore or improve bowel and bladder function for two of five residents reviewed. (Residents R8 and R41)

Findings include:

Review of the facility policy titled urinary continence and incontinence assessment and management dated August 2022 revealed that it was the responsibility of the staff to screen for management of individuals with urinay incontinence. The policy indicated that staff will provide appropriate services and treatment to ensure residents restore or improve bladder function and prevent urinary tract infections to the extent possible.

Hosptal record review indicated that Resident R41 was admitted to the hospital on April 5, 2025 and was treated for nephrolitiasis (kidney stones).

Clinical record review for Resident R41 revealed an admission comprehensive MDS (Minimun data Set- assessment of resident's needs) assessment dated April 22, 2025 that indicated this resident was cognitively intact. The assessment also indicated that the resident was dependent for toileting (ability to maintain perineal hygiene after use of the bedpan, toilet, commode or toilet). The assessment also indicated that this resident was frequently incontinent of bladder and had no functional impairments of the upper and lower extremities.

Interview with Resident R41 at 11:30 a.m., on May 13, 2025 revealed that the resident was tired of wearing the brief and wanted to try a toileting program.

Clinical record review revealed that there was no documentation to indicated that a voiding study to determine voiding patterns or types of incontinence had been developed and implemented for Resident R41.

Clinical record review revealed that there was no documentation to indicate that a toileting trial and its' results had been implemented for Resident R41's care needs for urinary incontinence..

Interview with registered nurse, Employee E31 at 10:30 a.m., on May 14, 2025 confirmed that Resident R41 was able to let staff know when he had to have assistance with toileting and toileting transfers. The registered nurse, Employee E31, also confirmed that Resident R41 was wearing a brief and was not trialed for a toileting program based on a documented voiding trial.

Clinical record review for Resident R8 revealed an admission comprehensive assessment (MDS-an assessment of care needs) dated April 26, 2025 that indicated this resident was frequently incontinent of urine and at risk for pressure ulcer development, having a stage II (ulcer involving loss of the top layers of the skin) pressure ulcer. The assessment also indicated that Resident R8 was alert and oriented and had no upper or lower extremity impairments. The assessment also said that Resident R8 was toilet, chair/bed transfer dependent, non-ambulatory and dependent on staff to assist with a roll left to right while in bed.

Interview with Resident R8 at 11:00 a.m., on May 16, 2025 revealed that the resident was able to left staff know when she needed toileting. The resident said that it comes quick and hard to hold her bladder. Resident R8 explained that she would be willing to try a bedpan for her toileting needs; instead of a brief.

Clinical record review revealed that there was no documentation to indicated that a voiding study to determine voiding patterns or types of incontinence had been developed and implemented for Resident R8.

Clinical record review revealed that there was no documentation to indicate that a toileting trial and its' results had been implemented for Resident R41's care needs for urinary incontinence.

Interview with Resident R8's nursing assistant, Employee E25, at 11:10 a.m., on May 16, 2025 revealed that Resident R8 could hold the enabler side rail for turning in bed with staff assistance. The nursing assistant confirmed that Resident R8 was alert and oriented and able to let staff know about her toileting needs.

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

28 PA. Code 211.10(a)(b)(c)(d) Resident care policies






 Plan of Correction - To be completed: 07/08/2025

- Resident 41 will have a bladder evaluation to determine if the toileting program is appropriate
- Resident 8 will have bladder evaluation to determine if toileting program is appropriate
- Initial Audit of current residents who have been identified as incontinent during a 90 day look back will be reevaluated to determine an appropriate toileting program
- Education to licensed nurses and nurse aides on Continence and Incontinence Assessment and management policy
- Weekly audits x 4 then monthly x 2 to be completed for those residents appropriate for program
- Results of audits will be presented to QAPI

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:

Based on clinical record review and interview with staff, it was determined that the facility did not ensure that care plans were revised in a timely manner related to hopsice services, enternal feeding, and intravenous device for three of nineteen records reviewed (Resident R18, R36, and R80).

Findings include:

Review of facility policy titled, "Care Plans, Comprehensive Person-Centered" revised March 2022 states, "Policy Statement- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident." "12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; c. when the resident has been readmitted to the facility from a hospital stay; and d. at least quarterly, in conjunction with the required quarterly MDS statement".

Review of Resident R18's clinical record revealed the resident was admitted to the facility on March 11, 2025 with the following diagnoses: Hyptertensive Heart Disease with Heart Failure, Aphasia (difficulty speaking), and Adult Failure to Thrive.

Review of Resident R18's hospice records revealed the resident entered into hospice services on April 16, 2025.

Review of Resident R18's care plan revealed the resident did not have a had a care plan in place to address the goals and/or interventions for hospice services.

Review of Resident R36's clinical record revealed the resident was admitted to the facility on August 20, 2024 with the following diagnoses: Dysphagia (inability to swallow), Dementia (progressive degenerative disease of the brain), Type 2 Diabetes (failure of the body to produce insulin) and gastrostomy (a surgical placed device used to give direct access to the stomach for supplemental feeding, hydration or medication).

A tour was taken of the first floor nursing unit on May 13, 2025 at 10:30 a.m. After entering Resident R36's room it was noted that the Resident R36 had an enternal tube feed placed next to her bed that was engaged. Review of Resident R36's physician orders revealed a physician order from February 11, 2025 of "Start Tube Feed at 2PM via PEG tube".

Review of Resident R36's current care plan dated September 10, 2024 states, "Resident has an enternal feeding tube to meet nutritional needs, Date Initiated: 08/20/2024 Cancelled Date: 09/10/2024" Review of Resident R36's current plan revealed there is no current goal or interventions for the residents enternal feeding.

Review of Resident R80's clinical record revealedthat the resident was oriented to person, with medical history of severe intellectual disability, borderline personality disorder, anxiety disorder, cognitive communication deficit.

Review of facility provided incident list for months of April 2025 and May 2025, revealed that Resident R80 had a 'medical device/tube dislodgment' three times for the month of April 2025; on April 23, 2025 at 9:42 p.m., April 23, 2025 at 6:30 a.m., and April 18, 2025 at 4:00 p.m..

Review of nursing notes, dated April 23, 2025 at 8:15 a.m., revealed that the resident had right hand peripheral intravenous line placed for IV (intravenous) fluids and received 600 ml out of 100 ml of normal saline solution before pulling out IV.

Further review of nursing progress notes, dated April 24, 2025 at 1:49 a.m., revealed that at approximately 9:30 p.m., resident was found with disconnected IV tubing again. It was also noted that this resident flooded her bathroom into the hallway.."

Further review of R80's nursing progress notes, dated April 18, 2025 at 1747, revealed that "On 4/18/25, resident's IV dislodged, MD into visit received order to start hypodermoclysis (method of infusing fluids into the subcutaneous tissue to rehydrate a patient)."

Review of incident report completed on Friday, April 18, 2025 at 4:00 p.m., revealed that staff were "warned prior to administration by case manager that resident may pull IV out as she has done so in the hosptal." Root cause for dislodgement was due to resident diagnosis of "intellectual disabiity (IDD) and nonverbal and does not understand necessity of the ivf's."

Review of incident report completed on April 23, 2025 at 0942, indicates peripheral IV line was dislodged again due to resident's behavior and related to IDD diagnosis and inability to understand need.

Review of R80's care plan revealed no evidence of goals and interventions related to resident's mental status and non-compliance with intravenous line device.

28 Pa Code 211.10(d) resident care policies

28 Pa Code 211.12nursing services




 Plan of Correction - To be completed: 07/08/2025

- Resident 18 is currently not in the building or on hospice and no longer resides in the facility.
- Resident 36 enteral feed care plans to be updated with current goal and interventions
- Resident R80 has been discharged from facility
- Initial Audit to identify current residents with IV therapy, hospice, and enteral feeds to ensure goals and interventions are appropriate.
- Director of Nursing will provide education to nursing, dietary, social service staff on comprehensive care plan policy
- Weekly Audits x 4 then monthly x 2 to be completed for timing of care plan revisions and appropriateness of interventions
- Results of audits will be presented to QAPI

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

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

Based on review of clinical records, hospital records,and facility policies and procedures, interviews with staff and residents and review of facility provided incident reports, it was determined that facility failed to ensure a complete evaluation of change in condition to address pain levels for one of 19 residents reviewed (Resident R62).

Findings include:

Review of facility policy 'Change in a Resident's Condition or Status,' revised February 2021, indicates that the nurse will notify the resident's attending physician or physician on call when there has been an accident or incident involving the resident; adverse reaction to medication; significant change in the resident's physical/emotional/ mental condition. The policy also indicated that a significant change in a resident's physicial, mental or psychosocial status was a deterioration in health, mental or psychocial status with clinical complications. The nursing staff and other professional staff were responsible to notify the physician with all pertinent information for the need to alter treatment significantly, begin a new form of treatment or a decision to transfer the resident for futher assessment and treatment.

Hospital record review for Resident R62 revealed a hospitalization on March 6, 2025 for a fall while walking. The resident tripped on a rock and fell landing on the right hip. Hospital record review revealed a hospitalization for Resident R62 on March 16, 2025 where the resident slid out of bed and was unable to get up for about 30 minutes. The resident reported right hip and right knee pain post fall.

Review for Resident R62's clinical record revealed an admission comprehensive assessment (MDS-an assessment of care needs) dated April 1, 2025 that indicated this resident was admitted to the facility on March 26, 2025. The assessment indicated that this resident was cognitively intact, used a walker, required maximum assistance of staff to perform the activity of sit to standx, required moderate assistance from staff for chair/bed to chair transfers and walking 10 feet was not attempted by the resident. The assessment also indicated that this resident had a fall history of falling in the last two to six months prior to admission. The resident was receiving occupational and physical therapy at the facility.


Clinical record review for Resident R62 revealed an admission note dated March 27, 2025 that indicated this resident was admitted with hip, pelvis and knee pain from a fall.

Clinical record review revealed a nursing note dated March 28, 2025 that indicated Resident R62 exhibited weakness with activities of daily living and Resident R62 was wearing a hard boot for immobilization to the right leg.

Review of nursing note dated March 29, 2025 revealed that the resident exhibited unsteady gait impairment, balance and weakness with functional status.

On April 4, 2025 the physician indicated that Resident R62 reported being in pain intermittently and that Tylenol was not addressing the pain. The physician indicated that the pain was in the right hip and knee. The pain level was moderate according to the resident.

Clinical record review revealed an Occupational therapy progress note on March 27, 2025 indicated Resident R62 was verbalizing constant pain of the right lower extremity that was limiting functional activities. The therapist indicated that pain was exacerbated with standing for Resident R62. On April 9, 2025 the occupational therapist indicated that Resident R62 was only able to stand supported for 30 to 60 seconds.

Clinical record review revealed a nursing note dated April 15, 2025 that indicated Tramadol (opiod used to treat pain) was indicated for knee pain and ambulatory dysfunction for Resident R62.

Clinical record review revealed that the nursing staff failed to obtained a physician's order and discuss Resident R62's pain level and the need for Tramadol for knee pain and ambulatory dysfunction with resident's physician.

Clinical record review revealed a physician's note dated April 21, 2025 that indicated Resident R62 complained of chronic pain in the right hip. The physician's progress note mentioned continue tramodol (opiod used to treat pain) for knee pain.

Interview with the registered nurse, Employee E3, at 1:00 p.m., on May 15, 2025 confirmed that the nursing staff failed to notify the physician of a significant change in medical condition for Resident R62 on April 15, 2025. The registered nurse, Employee E3 also confirmed that there was no indication that Tramadol had been administered to Resident R62 on April 15, 2025 or April 21, 2025.

Clinical record review revealed that the occupational therapist spoke to the responsible party for Resident R62 on April 21, 2025 and explained the lack of progress in therapy due to the resident's experience of pain in the right leg. The therapist documented that Resident R62 required moderate assist with transfers wheel chair to bed due to continually reporting severe pain with movement and weight baring in right lower extremity.

Interview with Employee E38, occupational therapist, at 2:00 p.m., on May 15, 2025 confirmed that throughout therapy sessions March 27 through April 21, 2025 Resident R62 was limited in acheiving functional mobility goals due to concerns of pain upon movement.

Interview with the registered nurse, Employee E3, at 2:30 p.m., on May 15, 2025 confirmed that there was a lack on monitoring of the onset, duration and severity of medical changes in Resident R62's right leg to inform the physician so that treatment was adjusted accordingly.

Clinical record review revealed on April 25, 2025 Resident R62 was sent to the hospital with an injury of unknown origin. At the hospital Resident R62 was diagnosed with a deformed fracture of the right femur.

Interview with Resident R62 at 10:00 a.m., on May 14, 2025 revealed that the resident had no falls at the facility. Resident R62 reported that he had two falls at home.

28 PA. Code 211.10(c)(d) Resident care policies

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






 Plan of Correction - To be completed: 07/08/2025

- Facility cannot retro actively correct deficient practice for resident 62. Resident 62 will have a current pain evaluation completed and review of current pain medication by MD/ NP.
- Facility will complete an audit of current resident who have had a change in condition in the past 7 days to ensure the MD/ NP was notified of the change in condition, any new orders given are transcribed / implemented appropriately, and documentation in progress notes is present.
- The Staff Development Coordinator / designee will educate licensed nursing staff on the facility policy "Change in Residents Condition or Status"
- The Director of Nursing/ Designee will conduct audits to ensure residents with noted changes in condition have appropriate documentation of notification to MD and follow through with new orders/interventions. Random audits will be conducted weekly x 4 then monthly x 2.
- Results will be submitted to QAPI for review and recommendations as need

483.10(j)(1)-(4) REQUIREMENT Grievances: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(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 a review of facility policy and procedures, resident group interview, staff interview, and observations it was determined that the facility failed to ensure that the grievance forms were available and accessible to residents on two of two nursing units reviewed. (First Floor and Second Floor Units)

Findings include:

A review of facility policy titled "Grievances/Complaints, Filing" dated April 2017 states, "Policy Statemen-Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman)." "5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously." "7. The administrator is the facility grievance officer."

During a resident council meeting on May 14, 2025, at 10:15 a.m. held on the second floor with four alert and oriented residents reported that they were not aware how to file a grievance or where to find a grievance form at the facility. (Residents R17, R58, R61, R77)

A review of a Grievance/Concern Form revealed there is no space to indicate the grievance is being filed anonymously.

A tour was taken with the Director of Social Services, Employee E8 of the First Floor and Second Floor Nursing units with the Employee E8 on May 14, 2025 at 11:05 a.m. to look for required grievance forms. The tour revealed that there were no grievance forms accessible for residents, family, or advocates. There were also no labeled locked boxes for anonymous grievances to be turned in to.

The Nursing Home Administrator, Employee E1 confirmed the above findings on May15, 2025 at 2:11 p.m.

28 Pa. Code 201.14(a)Responsibility of licensee

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

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

28 Pa. Code 201.29(a)Resident rights








 Plan of Correction - To be completed: 07/08/2025

- Grievance forms secured boxes and information on contacting the grievance officer have been made available and accessible to residents near both first floor, and second floor nursing unit.
- Residents R17, R58, R61 and R77 will be educated on submitting a grievance and contacting the grievance officer. Process will be reviewed with all residents at next monthly resident council meeting
- Social Services/designee will be educated to ensure that the grievance forms are available and accessible to residents in both first, and second floor units.
- Social Services/designee will conduct an audit weekly x 4, then monthly x 2 to ensure that the grievance forms are available to residents on both first and second floors.
- Results of the audit will be presented to the QAPI committee at the subsequent meeting.

483.20(b)(2)(ii) REQUIREMENT Comprehensive Assessment After Signifcant Chg: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(b)(2)(ii) Within 14 days after the facility determines, or should have determined, that there has been a significant change in the resident's physical or mental condition. (For purpose of this section, a "significant change" means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions, that has an impact on more than one area of the resident's health status, and requires interdisciplinary review or revision of the care plan, or both.)
Observations:

Based on a review of clinical records and staff interviews, it was determined the facility failed to conduct a significant change assessment for one of nineteen residents reviewed (Resident R28).

Findings include:

According to the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides guidance and instructions for the completion of Minimum Data Set (MDS - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) assessments dated October 2023, the facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines or should have determined that there has been a significant change in the resident's physical or mental condition. The RAI Manual indicates a "significant change" is a major decline or improvement in a resident's status that: 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered "self-limiting"; 2. Impacts more than one area of the resident's health status; and 3. Requires interdisciplinary review and/or revision of the care plan."

Review of Resident R28's clinical record revealed that the resident was admitted to the facility on November 19, 2024 with diagnosis of dysphagia (problem swallowing), Muscle Wasting and Atrophy, Heart Failure, Hypertension (high blood pressure) and Dementia progressive degenerative disease of the brain). The resident had her weight taken upon admission on November 19, 2024 which was 175.4 pounds. The resident was being weighed ongoing. Further review of Resident R28's weight record revealed the resident was weighed on January 14, 2025 and she weighed 155 pounds.

Review of the resident's "Weight Change Note" from January 15, 2025 states, "Resident now triggered for significant weight change. History of Dementia and confusion noted. Resident with poor intake and refuses some food and drinks. Her intakes are poor to fair per nursing documentation. Resident is on a regular, mechanical soft, nectar thick liquid diet which has been advanced this morning to thin liquids per speech. Resident was start on house shakes two times a day on January 13, 2025. She is Flu A positive which may be negatively affecting her appetite as well. If accurate, resident with 9.4%, 16-pound weight loss in 1 week. Writer questions the accuracy of weight change within this time frame. Suspect scale error versus inaccurate weight documentation. Current Body Weight was obtained on mechanical lift versus other weights obtained on sitting scale. Possible discrepancy. Will monitor reweigh and weight trends throughout admission. Please continue to encourage intakes and provide assistance at meal times. Offer snacks and favorite foods/food from home as able. Registered Dietician remains available and will follow up as needed".

Review of Resident R28's clinical record revealed a Weight Change Note from February 5, 2025 stating, "Resident reviewed for follow up for significant weight changes. Resident continues with poor appetite and poor to fair intakes per nursing. She is awake and oriented times two at her baseline. Resident tolerates a regular, mechanical soft diet with houseshakes twice a day. Resident does enjoy the chocolate house shakes and likes desserts and sweets but often does not eat her main meal. She complains the food tasting too salty to her and not feeling hungry. Suggest offer snacks/favorite foods as able. Weight Status: Body Mass Index: 30.9 Current Body Weight 2/3: 158.1#"

Review of Resident R28's clinical record revealed the resident did not have a MDS Change of Condition Evaluation completed in the month of January after the significant weight loss was identified by the facility dietician.

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











 Plan of Correction - To be completed: 07/08/2025

- Facility is not able to retroactively correct deficient practice for Resident 28 had weight changes and Significant Change MDS not completed,
- Initial Audit will be completed of current residents who in the past 30 days who have triggered for a significant weight change to ensure that a significant change MDS was completed.
- Director of Nursing will provide education to IDT and RNACS of facility on Comprehensive Assessment Policy
- Weekly Audits x 4 then monthly x 2 to be completed residents trigger for weight changes and completed MDS for Significant Change
- Results of audits will be presented to QAPI

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

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

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

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

Based on review of facility provided documentation and review of clinical record, it was determined facility did not ensure to maintain nutrition status according to professional standards of practice for a resident receiving total parenteral nutrition one of 19 residents reviewed. (Resident R71)

Findings include:

Review of facility policy 'Administering Medications,' revised April 2019, indicates that the individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include:
a. Checking identification band;
b. Checking photograph attached to medical record; and
c. If necessary, verifying resident identification with other facility personnel

Review of Resident R71's clinical record revealed that the resident, was awake alert and oriented x 3 (people, place and time), with medical history of hypokalemia (disorder of low potassium), cardiac arrest, hypomagnesemia, tracheostomy (tube inserted through the neck to assist with breathing) status, diabetes type 2 (failure of the body to produce insulin), ileostomy, fistula of stomach and duodenum, abnormal findings of blood chemistry.

Further review of R71's clinical record revealed that on April 8, 2025, licensed nurse, employee E28, administered R239's total parenteral nutrition (TPN- receives al nutrients through the vein)) to Resident R71; resulting in vomiting and low potassium level in blood.

Review of facility provided incident report conclusion was that R71 was "noted to have wrong TPN formula hanging by oncoming staff. TPN was removed, picc line flushed. Nurse practitioner and physician notified , orders for labs were given and completed. New TPN formula was placed ..."

Further review of incident report revealed root cause of incident was " TPN was not hung on the correct patient and the TPN policy was not followed to ensure the correct patient, formula and MD order and correct rate."

Review of facility's infection preventionist statement revealed "I came into the room to complete wound care with the wound care team in the am and noticed that the TPN bag hanging that was hanging had a different patients name on it. I immediately took it down and we notified the DON, NP, labs were ordered and correct TPN was re-placed."
Statement from Resident R71 revealed that "a nurse hung TPN at 2 am, couple of nights ago, but it was not hung up last night."

Further review of facility provided information, revealed Resident R71 was administered Resident R239's TPN; R239 clinical record revealed she had an order for TPN consisting of amino acids 80g, dextrose 250g, lipids 20g, KCL 10mEq, Kacetate 10mEq, NaCl 120 mEq, NaAcet 80 mEq, NaPhos 20 mEq, MagSul 8 mEq, CaGluc 8 mEq, MVI w/K 10 ml, Tral 1 ml, folic acid 1 mg, ascorbic acid 500mg, zinc 10mg.

Review of R71's clinical record revealed she had an order for TPN consisting of amino acids 15% 90g, dextrose 240g, lipids 20% 0g, sodium acetate 100meq, sodium phosphate 10mmole, KCL 60meq, mg sulfate 30 meq, Ca gluconate 15meq, MVI w/Vitamin K 10 ml, tralement4 1 ml, thiamine 60mg.

Further review of facility provided incident report revealed that licensed nurse, Employee E28 was assigned to Resident R71 on Monday, April 8, 2025 night shift. Per Employee E28's statement "had to hang a new bag of TPN early morning hours. I went into the med room and removed from the refrigerator once at room temperature, 9 went to patient's room and hung the TPN. I did not know someone else was on TPN and did not check the name on the label . I also did not take another nurse with me."

Further review of statement taken from licensed nurse, employee E29, on April 9, 2025, revealed that she "was assigned to patient last night, the TPN was infusing, I did not have to hang a new bag, I did not check to ensure the name was for the correct patient."

Further review of statement taken from licensed nurse, Employee E30, on April 9, 2025, states " I was assigned to patient on April 8, 2025, 7am to 7pm, her TPN was infusing the whole time, I did not have to hang a new bag. I did not check the bag to ensure the name, formula and rate were correct."

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

28 Pa Code 201.14(a) responsibility of licensee






 Plan of Correction - To be completed: 07/08/2025

- Resident 71 will have the correct TPN formula infused as ordered
- Facility is unable to retro actively correct deficient practice.
- An initial audit will be conducted of all current residents who are receiving/ ordered, to ensure parental nutrition policy is being followed
- Director of nursing / designee will educate all licensed nursing staff on the facility policy Total parental nutrition
- Audits will be completed daily x 7 days, weekly x 4 and monthly x 2 to ensure the appropriate TPN formula is being administered to the appropriate patient. Results of audits will be presented to QAPI

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 clinical record review, review of facility policy and interviews with staff, it was determined that the facility failed to maintain effective communication with a dialysis provider for one of two residents reviewed. (Residents R74)

Findings Include:

Review of facility policy titled "End-Stage Renal Disease, Care of a Resident with" with a revision date of September 2010 states, "4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: a. how the care plan will be developed and implemented: b. how information will be exchanged between the facilities".

Review of Resident R74's quarterly MDS (Minimum Data Set - a mandatory periodic resident assessment tool) revealed that the resident was admitted to the facility on April 18, 2025, with the diagnosis of End Stage Renal Disease.

On May 15, 2025 at 2:02 p.m., Resident R74's dialysis communication with the facility was requested. A binder containing communication sheets with the resident's information and communication pages between the facility and the dialysis team was provided. Further review of the dialysis communication binder revealed there were several days that the communication sheets were not fully completed. "Section 3: Completed by the facility upon return from Dialysis" was not completed for the following dates: May 13, 2025, April 28, 2025, April 25, 2025, and April 21, 2025.

28 Pa. Code 211.(5)(f )Clinical records

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








 Plan of Correction - To be completed: 07/08/2025

- Resident 74 has been discharged from facility
- Initial Audit of current Dialysis patients will be conducted to ensure that dialysis communication records are completed per facility policy
- Education will be provided to Licensed nurses on completion of Communication Record / Form
- Weekly Audits x 4 then monthly x 2 on dialysis patients to ensure the Communication Record is completed
- Results of findings will be presented to QAPI

483.30(a)(1)(2) REQUIREMENT Resident's Care Supervised by a Physician: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.
§483.30 Physician Services
A physician must personally approve in writing a recommendation that an individual be admitted to a facility. Each resident must remain under the care of a physician. A physician, physician assistant, nurse practitioner, or clinical nurse specialist must provide orders for the resident's immediate care and needs.

§483.30(a) Physician Supervision.
The facility must ensure that-

§483.30(a)(1) The medical care of each resident is supervised by a physician;

§483.30(a)(2) Another physician supervises the medical care of residents when their attending physician is unavailable.
Observations:

Based on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician assessment was completed related to unplanned weight loss for one of nineteen residents reviewed (Resident R28).

Findings include:

Review of clinical documentation for Resident R28 revealed that she was re-admitted to the facility on February 28, 2025 and had diagnoses of; Muscle Wasting and Atrophy, Dysphagia, and Dementia.

Review of the resident's weight documentation revealed that on August 9, 2024, the resident weighed 175.4 pounds on November 19, 2024. The resident was weighed again on January 7, 2025, and weighed 171. The resident was weighed again a week later on January 14, 2025, and the resident weighed 155 pounds.

Review of Resident R28's "Weight Change Note" from January 15, 2025 states, "Resident now triggered for significant weight change. History of Dementia and confusion noted. Resident with poor intake and refuses some food and drinks. Her intakes are poor to fair per nursing documentation. Resident is on a regular, mechanical soft, nectar thick liquid diet which has been advanced this morning to thin liquids per speech. Resident was start on house shakes two times a day on January 13, 2025. She is Flu A positive which may be negatively affecting her appetite as well. If accurate, resident with 9.4%, 16-pound weight loss in 1 week. Writer questions the accuracy of weight change within this time frame. Suspect scale error versus inaccurate weight documentation. Current Body Weight was obtained on mechanical lift versus other weights obtained on sitting scale. Possible discrepancy. Will monitor reweight and weight trends throughout admission. Please continue to encourage itakes and provide assistance at meal times. Offer snacks and favorite foods/food from home as able. Registered Dietician remains available and will follow up as needed".

Further review of Resident R28's clinical record revealed a Weight Change Note from March 18, 2025 stating, "Resident reviewed for follow up for history of significant weight changes. Resident continues with decreased appetite and poor to fair intakes per nursing....3/1 Current Body Weight: 155.1# Resident with 9.3%, 13# weight loss in 2 months which is clinically significant weight loss."

Review of Resident R28's clinical record revealed a Weight Change Note from February 5, 2025 stating, "Resident reviewed for follow up for significant weight changes. Resident continues with poor appetite and poor to fair intakes per nursing. She is awake and oriented times two at her baseline. Resident tolerates a regular, mechanical soft diet with houseshakes twice a day. Resident does enjoy the chocolate house shakes and likes desserts and sweets but often does not eat her main meal. She complains the food tasting too salty to her and not feeling hungry. Suggest offer snacks/favorite foods as able. Weight Status: Body Mass Index: 30.9 Current Body Weight 2/3: 158.1#"

Final review of Resident R28's clinical record revealed the resident was recently weighed on May 8, 2025 and has a current body weight of only 157.1 pounds.

There was no documentated evidence that the physician was notified about Resident R28's significant weight loss. There was no indication that a physician evaluated the residents significant weight loss.

Interview with the Regional Director of Nursing, Employee E3 on May 16, 2024, at 1:05 p.m. confirmed the resident's physician had not been notified or did not document an assessment of the potential medical causes of Resident R28's recent significant weight loss.


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

28 Pa. Code: 211.2(a) Physician services.

28 Pa. Code: 211.5(f) Clinical records









 Plan of Correction - To be completed: 07/08/2025

- Resident 28 will have weights reviewed by facility dietician and notification to provider of changes will be made and documented
- An initial audit of current residents with significant weight change in the past 30 days will be conducted to ensure that the physician was notified and notification is documented with new orders given
- Education will be provided to licensed nurses, dieticians on weight assessment and intervention policy
- Weekly audits x 4 then monthly x 2 to be completed on residents who are identified with having a significant weight change to ensure that the physician was notified and documentation is present for notification and any new orders that were given
- Results of findings to be presented to QAPI

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly: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.
§483.60(i)(4)- Dispose of garbage and refuse properly.
Observations:

Based on reviews of policies and procedures, observations of the outdoor loading and receiving area and interviews with staff, it was determined that the facility was not disposing of garbage and refuse properly.

Findings include:

A review of the policy titled cleaning and sanitizing of the food service areas, it was indicated that the food service director was responsible for devising a comprehensive cleaning schedule for dietary staff to complete daily. The director of dietary services was to determine all cleaning and sanitation tasks needed for the operation of the food and nutrition services department. frequency of cleaning as necessary. The director of dietary services was responsible for posting a cleaning schedule for all cleaning tasks, and staff will initial the tasks as completed. The policy indicated that staff will be held accountable for cleaning assignments.

A review of the cleaning schedules and responsibilitites of the dietary staff to include the proper disposal of the kitchen garbage and trash revealed that there was no comprehensive cleaning schedule developed for this function of the dietary department.

Interview with the director of dietary service, Employee E37, at 10:20 a.m., on May 13, 2025 confirmed that there was no documented dietary staff cleaning schedules posted or developed for the routine cleaning, sanitizing and storage of trash containers, cooking grease, garbage and trash accumulated by the dietary department.

Observations at 10:15 a.m., on May 13, 2025 of the outdoor loading and receiving area that was located adjacent to the food and nutrition services department revealed that waste was not covered and contained with a lid on top of the dumpster/compactor unit.

The driveway area surrounding the dumpster/compactor unit was not free of debris. Torn open plastic bags of garbage (soiled briefs, food debris, papers and plastic gloves) was observed on the ground.

Foul odors and waste fat was evident on the loading dock. The dumpster/compactor was located directly infront of the loading and receiving area of the building and was the storage area for the garbage and trash for the entire facility.

This area was not being maintained in a sanitary manner to prevent the harborage and feeding of pests and rodents.

28 PA. Code 211.10(a)(b)(c)(d) Resident care policies

28 PA. Code 201.14 (a) Responsibility of licensee

28 PA. Code 201.18(e)(1)(2.1) Management




 Plan of Correction - To be completed: 07/08/2025

- The daily cleaning schedule for dietary staff has been completed and posted, which includes the storage of trash and garbage by staff.
- Facility has reached out to the Waste Management company, and an evaluation for repair/replacement of the lid/cover to the dumpster, or a replacement dumpster, will be completed by Waste Management technician. Facility will ensure that a replacement lid, or dumpster is installed for proper disposal of garbage.
- Surrounding trash and debris to the dumpster will be cleaned by Housekeeping/Maintenance to prevent harboring pests and rodents.
- Dietary/Housekeeping and Maintenance Director will be educated on posting the cleaning schedule, storage of trash containers, and ensuring that there is a lid covering the dumpster, Compactor unit.
- The Maintenance Director will conduct an audit weekly x4, then monthly x2 to ensure that the facility is in compliance with disposing of garbage and refuse properly.
- Results of the audit will be reviewed at the subsequent QAPI meeting.

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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.
§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:

Based on an environmental tour and observations of the food and nutrition services department, interviews with staff and reviews of equipment purchase orders, it was determined that the facility was not maintaining essential equipment for the dietary services department in safe operating condition.

Findings include:

Observations of the ice machine located in the food and nutrition department revealed that it was not functioning.

Interviews with the maintenance director, Employee E26, at 10:30 a.m., on May 13, 2025 revealed that the ice machine inside the main kitchen of the food and nutrition services department had been out of service since, January, 2025.

Interview with the director of dietary services, Employee E36 confirmed that the essential equipment (industrial-sized ice maker machine) had not been operational for months. A work order was placed in January, 2025 to repair the ice machine. The director of dietary services said that the dietary staff were forced to use the second floor nursing units' ice machine or have ice delivered in bags from an outside vender.

A review of the purchase order requisition made by the dietary services department was dated May 6, 2025. The director of maintenance repoted that there was no delivery date for the ice machine to arrive at the facility.

28 PA. Code 201.18(b)(1)(3)(e)(1)(2.1) Management




 Plan of Correction - To be completed: 07/08/2025

- A replacement, functioning ice machine has been installed in the Dietary department.
- An initial audit of essential equipment in the Dietary Department will be completed by the Maintenance Director/designee to ensure that essential equipment is operational and functioning properly.
- The Maintenance Director/designee will be educating to ensure that essential equipment is operating and functioning properly.
- The maintenance Director/designee will conduct a weekly audit x4, then monthly x2 to ensure that the ice machine and essential equipment are operating and functioning properly.

483.90(i)(4) REQUIREMENT Maintains Effective Pest Control Program: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.
§483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.
Observations:

Based on observations of the food and nutrition department, reviews of policies and procedures and interviews with staff, it was determined that the facility failed to maintain an an effective pest control program in the dietary department.

Findings include:

A review of the undated facility policy titled pest control revealed that it was the responsibility of food service director to take appropriate action to eliminate pests in the main kitchen. The policy indicated that a pest control contractor would be contacted to complete preventative treatments at appointed times. The pest control operator would be contacted to visit the facility. The pest control contractor will document all visits along with actions taken. Pest traps and chemical treatments will be done by the certified pest control operator.

Observations of the main kitchen at 10:00 a.m., on May 13, 2025 were made with Employee E37, the director of dietary services. The main kitchen of the food and nutrition service department was considered the foodservice operation; where all foods and beverages were prepared, distributed and served to the residents daily.

The flooring of the entire perimeter of the main kitchen was heavily soiled with food debris, dirt and rodent droppings.

The heaviest accumulation of food debris cooking grease dirt and rodent droppings was underneath lare pieces of industrial-sized food service equipment (ovens, stoves, grills, prepartion tables, tray- line assembly area, refrigerators, juice machine and dry food storage shelves).

The metal doors leading directly onto the loading and receiving area of the facility were not sealing completely. These doors were located adjacent to the food and nutrition services department. Upon closing these doors, the threshold of the doorway was not sealed; allowing easy access to the building for pests and rodents. It was also noted that upon closing the doors, an air gap existed between the doors This also allowed easy access into the building for common household pests and rodents.

Upon opening the doors and walking out of the facility and onto the loading dock; a malorderous smell was present. The trash and refuse dumpster was opened to pests, rodents, birds and other mammals. Many plastic bags of trash (soiled briefs, food debris, papers and plastic gloves) and garbage were observed along side the dumpster unit. The plastic bags were torn open and scattered around the driveway located below the loading/receiving dock.

Reviews of the pest control operators reports for the months of January 2025 through April, 2025 were noted with treatment for common household pests (rodents). The pest control operator noted the kitchen anf front lobby as places in the facility that required continuous treatment.

28 PA. Code 201.14(a) Responsibility of licensee

28 PA. Code 201.18(b)(1)(3)(e)(1)(2.1) Management






 Plan of Correction - To be completed: 07/08/2025

- Dietary area/kitchen has been cleaned of soil and food debris. This included large equipment such as an oven and fridge in the Dietary area.
- The metal door identified has been sealed to prevent any access of rodent into the building.
- Loading dock and open/torn bags will be cleaned from the dumpster area to avoid pests. Maintenance will also follow up with any recommendations from Pest control following treatment for any pests.
- The maintenance Director/designee will be educated on the regulations to maintain a pest free environment.
- An initial audit of the pest log/visit will be completed to address any recommendations within the last 30 days. An ongoing audit will be completed weekly x4, when monthly x2 to ensure that the facility is maintaining a successful pest control program in the dietary department.
- Results of the audit will be presented to the QAPI committee at the subsequent meeting.

§ 201.22(b) LICENSURE Prevention, control and surveillance of tuber:State only Deficiency.
(b) Recommendations of the Centers for Disease Control and Prevention (CDC), United States Department of Health and Human Services (HHS) shall be followed in screening, testing and surveillance for TB and in treating and managing persons with confirmed or suspected TB.

Observations:

Based on review of personnel records and interview with staff, it was determined that the facility did not ensure to complete 2-step intradermal tuberculin (TB) skin testing for three of five employees reviewed (Employee E28, E29, E30)

Findings Include:

A request was made on May 14, 2025 at 10:05 a.m. for three employee files (Employees E28, E29, and E30).

Review of facility provided information revealed that Licensed Nurse, Employee E28, was hired on February 18, 2025, Licensed Nurse - Employee E29, was hired on April 6, 2017, and Licensed Nurse - Employee E30, was hired on February 10, 2000.

On May 15, 2025 the facility was unable to provide evidence of TB compliance for the three nursing employees upon request. Additional time was given to find the needed documentation but the facility was unable to provide.

Interview on May 16, 2025 at 9:14 a.m. with Employee E1, The Nursing Home Administrator confirmed the above findings.




 Plan of Correction - To be completed: 07/08/2025

- Employees 28, 29, 30 will be screened for Tuberculosis.
- An initial audit will be conducted of all current employees to ensure there is an initial screening for tuberculosis in their employee file. Variances identified will be addressed.
- Director of nursing/ designee will educate the facility staff development coordinator, human resource director and infection preventionist on the facility policy for tuberculosis screening of employees
- Audits will be conducted weekly x 4, then monthly x 2 to ensure that new employees hired have been screened appropriately for Tuberculosis. Results of the audit will be presented to the QAPI committee at the subsequent meeting.


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