Pennsylvania Department of Health
WAYNESBURG NURSING AND REHAB
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

WAYNESBURG NURSING AND REHAB
Inspection Results For:

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WAYNESBURG NURSING AND REHAB - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on February 5, 2026, it was determined that Waynesburg Health and Rehabilitation 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:

483.60(a)(1)(2) REQUIREMENT Qualified Dietary Staff:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. 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(a) Staffing
The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

This includes:
§483.60(a)(1) A qualified dietitian or other clinically qualified nutrition professional either full-time, part-time, or on a consultant basis. A qualified dietitian or other clinically qualified nutrition professional is one who-
(i) Holds a bachelor's or higher degree granted by a regionally accredited college or university in the United States (or an equivalent foreign degree) with completion of the academic requirements of a program in nutrition or dietetics accredited by an appropriate national accreditation organization recognized for this purpose.
(ii) Has completed at least 900 hours of supervised dietetics practice under the supervision of a registered dietitian or nutrition professional.
(iii) Is licensed or certified as a dietitian or nutrition professional by the State in which the services are performed. In a State that does not provide for licensure or certification, the individual will be deemed to have met this requirement if he or she is recognized as a "registered dietitian" by the Commission on Dietetic Registration or its successor organization, or meets the requirements of paragraphs (a)(1)(i) and (ii) of this section.
(iv) For dietitians hired or contracted with prior to November 28, 2016, meets these requirements no later than 5 years after November 28, 2016 or as required by state law.

§483.60(a)(2) If a qualified dietitian or other clinically qualified nutrition professional is not employed full-time, the facility must designate a person to serve as the director of food and nutrition services.
(i) The director of food and nutrition services must at a minimum meet one of the following qualifications-
(A) A certified dietary manager; or
(B) A certified food service manager; or
(C) Has similar national certification for food service management and safety from a national certifying body; or
D) Has an associate's or higher degree in food service management or in hospitality, if the course study includes food service or restaurant management, from an accredited institution of higher learning; or
(E) Has 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting and has completed a course of study in food safety and management, by no later than October 1, 2023, that includes topics integral to managing dietary operations including, but not limited to, foodborne illness, sanitation procedures, and food purchasing/receiving; and
(ii) In States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers, and
(iii) Receives frequently scheduled consultations from a qualified dietitian or other clinically qualified nutrition professional.

Observations: Based on review of job descriptions, and staff interviews, it was determined that the facility failed to employ a full-time qualified dietary services manager in the absence of a full-time qualified dietitian for 12 of 12 months. (February 2025 February 2026) Findings include: Review of facility policy "Dietary Services - Staffing" reviewed 1/31/25 and 1/7/26, indicated the facility employs sufficient staff with the appropriate competencies and skill set to carry out the functions of the Food and Nutrition Services. The facility will employ a qualified dietitian or other clinically qualified nutrition professional on a full time, part time, or consultant basis. If a qualified dietician is not employed full-time, the facility will designate a person to serve as director of food services who is a certified dietary manager, certified food service manager, has an associate's degree in food service management or two or more years of experience in the position of food and nutrition services in a nursing facility. Review of the job description for Registered Dietician (RD) indicated one of the essential functions in this position is to plan, organize, coordinate, and evaluate the nutritional components of dietary services for the facility. The essential job function included the following: - Assist in developing safety standards for the food and nutrition services department. - This position has supervisory responsibility for all dietary/kitchen personnel. Review of the job description for Dietary Supervisor indicated the dietary supervisor must demonstrate ability to organize, develop, and direct the overall operations of the Food Service Department in accordance with current state and local standards as well as established facility policies and procedures; assure that proper food quality and service is always provided. The essential job function included the following: - Assist in the development of, and participation in, programs designed for in-service education, on-the-job training, and orientation classes. - Inspect daily the food service area for compliance with current applicable regulations. - Develop and maintain a file of tested standard recipes. - Review the dietary requirements of each resident admitted to the facility and assist in planning of the resident's prescribed diet plan. - Check food production and food services to ensure proper procedures are always maintained. Education/Experience needed for the Dietary Supervisor position included: - High school diploma or equivalent required. - Successful completion of a reputable course in food service operation preferred. - College degree in culinary art and management. - Previous Experience in food service, preparation, and management. - Previous experience in institutional food service preferred During an interview on 2/4/26, at 8:35 a.m. Dietary Manager Employee E2 stated she completed her SERV Safe certification. she did not complete a Certified Dietary Manager (CDM) course. She started the current position on 12/28/25. She stated that she currently did not have her CDM (Certified Dietary Manager) and was not currently enrolled in the program. Review of the facility employee files indicated the following: - Employee E3 was hired 8/10/18, as a cook. Employee E3 accepted the position of Dietary Supervisor 11/7/23. His employee file did not include proof that he was qualified for the position, or a signed job description. Employee E3 left the facility's employ on 6/9/25. - Employee E5 was offered the Certified Dietary Manager position on 5/27/25. Employee E5 employee file failed to reveal proof she was qualified for the position as CDM or was enrolled in a CDM course. Employee E5 left the facility's employ on 7/30/25. - Employee E2 was offered the Certified Dietary Manager position on 8/25/25. Employee E2 employee file failed to reveal proof she was qualified for the position of CDM or was enrolled in a CDM course. During an interview on 2/4/26, at 9:20 a.m. Registered Dietician Employee E1 stated she is shared between two facilities. She works at the facility three days a week, and at a different facility two days a week. She confirmed she provides part-time services to the residents. During an interview on 2/4/26, at 2:00 p.m. the Nursing Home Administrator confirmed there was not a full-time dietitian employed at the facility and that the facility did not employ a qualified dietary manager in the absence of a full-time dietitian. 28 Pa. Code 201.18(b)(3) Management.

Plan of Correction - To be completed: 03/03/2026

Human Resource Manager educated by NHA on the requirement to employ a full-time qualified CDM in the absence of a fully qualified dietitian.
The Registered Dietitian has been designated as full time Dietician in the facility until a full-time CDM is hired or until the Dietary Manager is certified as a Certified Dietary Manager.
A Dietary Supervisor has been assigned responsibility for daily kitchen operations, including supervision of dietary staff, oversight of meal service, sanitation monitoring, and required documentation. The Dietary Supervisor is currently enrolled in an approved Certified Dietary Manager (CDM) training program and functions under the direct supervision of the Registered Dietitian with an estimated completion date of October 31st, 2026
The facility has placed an advertisement to fill the open full-time CDM position in the meantime.
Dietary Services policies and job descriptions have been revised to clearly define roles, responsibilities, and supervisory structure.
The Nursing Home Administrator (NHA) or designee will conduct and document weekly kitchen audits for four (4) weeks, followed by monthly audits for three (3) months, to ensure continued compliance with Registered Dietitian and Dietary Supervisor responsibilities.
The NHA and/or designee will also monitor and document the status of hiring a full-time CDM weekly x 4 weeks.
Audit results will be reviewed through the facility's QAPI program, and any identified concerns will be addressed immediately with corrective actions implemented as indicated.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

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

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Observations:

Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse or neglect for one of two residents reviewed (Resident R89).

Findings include:

Review of the facility policy "Abuse, Neglect and Exploitation" reviewed on 1/31/25 and 1/7/26, indicated an immediate investigation is warranted when suspicion, or reports of abuse, neglect, or exploitation occur. Written procedures for investigations include: identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations, and providing complete and thorough documentation of the investigation.

Review of the clinical record indicated Resident R89 was admitted to the facility on 2/16/23, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD caused by swelling and irritation in the airways that limit air going in and out of the lungs), other schizophrenia (serious mental disorder that affects how a person thinks, feels, and behaves), and generalized edema (excessive accumulation of fluid in the interstitial spaces throughout the body).

Review of a facility reported incident dated 12/10/25, revealed Resident R89 reported Nurse Aid (NA) for being rough and causing pain.

Review of the facility investigation revealed the residents interviewed did not sign or time the statements. The facility staff witness statements failed to include signatures or times.

During an interview on 2/3/26, at 1:30 p.m. Nursing Home Administrator (NHA) stated he conducted the staff interviews over the telephone and forgot to get the staff to sign when they returned to work. He stated he was not aware the residents had not signed their statements. The NHA confirmed the facility failed to conduct and document a thorough investigation in regard to Resident R89's incident.

28 Pa. Code: 201.149(a) Responsibility of licensee.

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

Plan of Correction - To be completed: 03/03/2026

The NHA and Social Services Director were immediately educated by DCO on the requirement to conduct thorough abuse and neglect investigations including ensuring that all residents and staff interview statements include signatures or times.
Social Service Director or designee immediately conducted house audit x 1 to ascertain that all abuse and neglect investigations completed in the last six months did not have missing signatures/times by interviewed residents and staff. No other investigations revealed any missing signatures/time for all interviewed residents and staff. No ill effects were experienced from the subject resident due to missing staff and resident signatures/time.
The facility NHA or designee will audit any new abuse and neglect investigations for missing signatures or time weekly 4 then monthly x 4, Results will be discussed in QAPI

483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:

§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

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

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

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

Observations: Based on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interviews it was determined that the facility failed to make certain comprehensive Minimum Data Set (MDS- periodic assessment of care needs) assessments were accurate and fully completed for one of eight residents (Resident R21). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set Assessments dated October 2025, indicated: Section B: Hearing, Speech and Vision, Question B0700: Makes Self Understood: Ability to express ideas and wants (consider both verbal and non-verbal expression) should be coded as "0" Understood, "1" Usually understood (difficulty communicating some words or finding thoughts but is able if prompted or given time), "2" Sometimes understood (ability is limited to making concrete requests), "3" Rarely/never understood. Section C: Cognitive Patterns, Question C0100: Should Brief Interview for Mental Status Be Conducted?" (BIMS) should be coded as "0" if the resident is rarely/never understood, or it should be coded as "1" Repetition of 3 words meaning the assessment should be completed (Questions C0200-C0500) if the resident is at least sometimes understood. Section D: Mood, Question D0100 "Should Resident Mood Interview Be Conducted?" should be coded as "0" if the resident is rarely/never understood, and or it should be coded "1," and the assessment should be completed if the resident is at least sometimes understood. Resident R21 had a MDS completed on 4/21/25. Review of Section B: Hearing, Speech and Vision indicated Resident R21 is "sometimes understood." Review of Section C: Cognitive Patterns, Question C0100 indicated that Resident R21 is coded as "1" repetition of 3 words, BIMS assessment was completed as Resident R21 scored 00, meaning the resident has severe cognitive decline. Review of Section D: Mood, Question D0100 indicated that Resident R21 is "understood" and the Resident Mood Interview assessment was not completed. Resident R21 had a MDS completed on 8/15/25. Review of Section B: Hearing, Speech and Vision indicated Resident R21 is "usually understood." Review of Section C: Cognitive Patterns, Question C0100 indicated the Resident R21 is rarely/never understood" and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R21 is "rarely understood" and the Resident Mood Interview assessment was not completed. Resident R21 had a MDS completed on 11/15/25. Review of Section B: Hearing, Speech and Vision indicated Resident R21 is "usually understood." Review of Section C: Cognitive Patterns, Question C0100 indicated the Resident R21 is rarely/never understood" and the BIMS assessment was not completed. Review of Section D: Mood, Question D0100 indicated that Resident R21 is "understood" and the Resident Mood Interview assessment was not completed. During an interview on 2/5/26, at 9:55 a.m. the Registered Nurse Assessment Coordinator (RNAC) confirmed the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed. During an interview on 2/5/26, at 10:55 a.m. the Nursing Home Administrator confirmed that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for one of eight residents (Resident R21). 28 Pa. Code: 211.5(f) Clinical Records.

Plan of Correction - To be completed: 03/03/2026

The RNAC and Social Services Director were immediately educated by the Regional Director of Clinical Reimbursement on the requirement to make certain that the comprehensive Minimum Data Set assessment is accurate and fully completed.
RNAC immediately corrected the MDS on the subject resident and resident did not suffer any ill effect from the inaccuracy of the assessment.
The RNAC immediately randomly selected 10 MDS and audited for accuracy of sections B0700, C0100 and D0100 of the MDS.
The RNAC or designee will complete an audit of all new admission for MDS accuracy assessments for sections B0700, C0100 and D0100 weekly x 4 and then monthly 2
Results will be discussed in QAPI

483.25(m) REQUIREMENT Trauma Informed Care:

§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, clinical record review, and staff interview, it was determined that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of post-traumatic stress disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of three residents reviewed (Resident R7). Findings include: Review of the facility policy, "Trauma Informed Care" dated 1/7/26 with a prior review date of 1/31/25, indicated that "A trauma-informed approach to care delivery recognized the widespread impact and signs and symptoms of trauma in residents, and incorporates knowledge about trauma into care plan, policies, procedures and practices to avoid re-traumatization." Review of the facility policy, "Care Plans, Comprehensive Person-Centered" dated 1/7/26 with a prior review date of 1/31/25, indicated that "A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, and functional needs is developed and implemented for each resident." Review of the clinical record indicated Resident R7 was admitted to the facility on 6/20/22. Review of Resident R7's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/1/25, indicated the diagnoses of post-traumatic stress disorder (PTSD - a psychiatric disorder that may occur in persons that have witnessed a traumatic event causing intense, disturbing thoughts and feelings related to the experience), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and anxiety. Section I6100 indicated PTSD is present. Review of Resident R7's facility diagnosis list indicated that the diagnosis of PTSD was added on 10/16/24. Review of Resident R7's care plan reveals a "trauma" care plan was not initiated until 2/2/26 during the full health survey. During an interview on 2/2/26, at 10:30 a.m. Resident R7 verbalized his history of being sexually victimized by predators for multiple years as a youth, while living in a group home. During an interview on 2/5/26, at approximately 10:45 a.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to ensure that residents received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of post-traumatic stress disorder. 28 Pa Code 201.24(e)(4) Admission Policy. 28 Pa Code 211.12(a)(d)(3)(5) Nursing Services. 28 Pa. Code 211.16(a) Social Services.

Plan of Correction - To be completed: 03/03/2026

The NHA immediately educated the Social Services Director regarding trauma-informed care, that 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 to eliminate or mitigate triggers that may cause re-traumatization of the resident

The Social Service Director completed an audit of all the residents in the facility with a diagnosis of post traumatic stress disorder to ensure that a trauma evaluation is complete as well as the presence and implementation of a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical and functional needs.
The subject resident did not suffer any side effects from lack of trauma-informed care to eliminate or mitigate triggers due to diagnosis of post-traumatic stress disorder.
Social Service Director or designee will complete audits on all new admissions for DX of PTSD, and make available trauma informed care where necessary 3x a week x 1week then weekly x 4
Results will be discussed in QAPI

483.70(n)(1)-(4) REQUIREMENT Hospice Services:

§483.70(n) Hospice services.
§483.70(n)(1) A long-term care (LTC) facility may do either of the following:
(i) Arrange for the provision of hospice services through an agreement with one or more Medicare-certified hospices.
(ii) Not arrange for the provision of hospice services at the facility through an agreement with a Medicare-certified hospice and assist the resident in transferring to a facility that will arrange for the provision of hospice services when a resident requests a transfer.

§483.70(n)(2) If hospice care is furnished in an LTC facility through an agreement as specified in paragraph (o)(1)(i) of this section with a hospice, the LTC facility must meet the following requirements:
(i) Ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility, and to the timeliness of the services.
(ii) Have a written agreement with the hospice that is signed by an authorized representative of the hospice and an authorized representative of the LTC facility before hospice care is furnished to any resident. The written agreement must set out at least the following:
(A) The services the hospice will provide.
(B) The hospice's responsibilities for determining the appropriate hospice plan of care as specified in §418.112 (d) of this chapter.
(C) The services the LTC facility will continue to provide based on each resident's plan of care.
(D) A communication process, including how the communication will be documented between the LTC facility and the hospice provider, to ensure that the needs of the resident are addressed and met 24 hours per day.
(E) A provision that the LTC facility immediately notifies the hospice about the following:
(1) A significant change in the resident's physical, mental, social, or emotional status.
(2) Clinical complications that suggest a need to alter the plan of care.
(3) A need to transfer the resident from the facility for any condition.
(4) The resident's death.
(F) A provision stating that the hospice assumes responsibility for determining the appropriate course of hospice care, including the determination to change the level of services provided.
(G) An agreement that it is the LTC facility's responsibility to furnish 24-hour room and board care, meet the resident's personal care and nursing needs in coordination with the hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs.
(H) A delineation of the hospice's responsibilities, including but not limited to, providing medical direction and management of the patient; nursing; counseling (including spiritual, dietary, and bereavement); social work; providing medical supplies, durable medical equipment, and drugs necessary for the palliation of pain and symptoms associated with the terminal illness and related conditions; and all other hospice services that are necessary for the care of the resident's terminal illness and related conditions.
(I) A provision that when the LTC facility personnel are responsible for the administration of prescribed therapies, including those therapies determined appropriate by the hospice and delineated in the hospice plan of care, the LTC facility personnel may administer the therapies where permitted by State law and as specified by the LTC facility.
(J) A provision stating that the LTC facility must report all alleged violations involving mistreatment, neglect, or verbal, mental, sexual, and physical abuse, including injuries of unknown source, and misappropriation of patient property by hospice personnel, to the hospice administrator immediately when the LTC facility becomes aware of the alleged violation.
(K) A delineation of the responsibilities of the hospice and the LTC facility to provide bereavement services to LTC facility staff.

§483.70(n)(3) Each LTC facility arranging for the provision of hospice care under a written agreement must designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident provided by the LTC facility staff and hospice staff. The interdisciplinary team member must have a clinical background, function within their State scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident.
The designated interdisciplinary team member is responsible for the following:
(i) Collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services.
(ii) Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family.
(iii) Ensuring that the LTC facility communicates with the hospice medical director, the patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians.
(iv) Obtaining the following information from the hospice:
(A) The most recent hospice plan of care specific to each patient.
(B) Hospice election form.
(C) Physician certification and recertification of the terminal illness specific to each patient.
(D) Names and contact information for hospice personnel involved in hospice care of each patient.
(E) Instructions on how to access the hospice's 24-hour on-call system.
(F) Hospice medication information specific to each patient.
(G) Hospice physician and attending physician (if any) orders specific to each patient.
(v) Ensuring that the LTC facility staff provides orientation in the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

§483.70(n)(4) Each LTC facility providing hospice care under a written agreement must ensure that each resident's written plan of care includes both the most recent hospice plan of care and a description of the services furnished by the LTC facility to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required at §483.24.

Observations:

Based on review of facility documents, clinical record review, and resident and staff interview, it was determined that the facility failed to complete a significant change on the Minimum Data Set (MDS - core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid) for one of three residents (Resident R9).

Findings include:

Review of facility policy "Coordination of Hospice Services" reviewed 1/31/25 and 1/7/26, indicated when a resident chooses to receive hospice care and services, the facility will coordinate and provide care in cooperation with hospice.

Review of the clinical record revealed Resident R9 was admitted to the facility on 9/23/25, with diagnoses that included cancer, high blood pressure, and depression.

A review of a physician's order dated 5/21/21, indicated that Resident R18 was admitted to hospice services.

Review of a physician's order dated 9/26/25, indicated admit to hospice.

Review of the MDS dated 10/1/25, failed to indicate Resident R9 was receiving hospice care and services.

A review of the communication between the facility and the hospice service, failed to reveal any documentation of nurse or home health aide visits to Resident R18.

A review of the care plan dated 9/27/25, indicated the hospice Resident R9 was receiving hospice care and services.

During an interview on 2/5/25, at 9:20 p.m. Registered Nurse Assessment Coordinator (RNAC) Employee E4 confirmed the MDS dated 10/1/25, failed to indicate Resident R9 was receiving hospice care and services and confirmed the facility failed to ensure provision of ordered hospice services for two residents.

28 PA Code: 211.10(c) Resident Care Policies

28 PA Code: 211.10(d) Resident Care Policies

28 PA Code: 201.18 (b)(1)(e)(1) Management.

28 PA Code: 211.12 (d)(2) Nursing Services.

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

Plan of Correction - To be completed: 03/03/2026

The RNAC and Social Services Director were immediately educated by the Regional Director of Clinical Reimbursement on the requirement to complete a significant change on the Minimum Data Set (MDS - core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid)
The subject resident did not suffer any side effects from lack of timely significant change MDS and no indication of nurse or home health visits in the medical record.
The RNAC immediately reviewed all hospice patients in the facility to ensure existence of significant change MDS and documentation nurse or home health aide
The RNAC or designee will audit for existence of significant change MDS and documentation nurse or home health aide visits for all new hospice admissions weekly x 4.
Results will be discussed in QAPI

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