Pennsylvania Department of Health
WHITEHALL BOROUGH POST ACUTE
Patient Care Inspection Results

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WHITEHALL BOROUGH POST ACUTE
Inspection Results For:

There are  188 surveys for this facility. Please select a date to view the survey results.

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WHITEHALL BOROUGH POST ACUTE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance, and an Abbreviated survey in response to three complaints completed on May 16, 2025, it was determined that Whitehall Borough Post Acute 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:


483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

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

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

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

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

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

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

§483.15(d) Notice of bed-hold policy and return-

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

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

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
Observations:
Based on a review of facility policy and documents, information provided by the State Ombudsman Office, clinical record reviews, and staff interviews, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of six residents reviewed for hospitalization (Resident R6, R89, R123, and R138) and failed to notify the State Ombudsman Office of resident transfers and discharges for two years (11/2023 through 12/2023, 1/2024 through 12/2024, and 1/2025 through 4/2025) as required.

Findings Include:

Review of federal regulation Notice of Bed-Hold Policy, indicated:
-Facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies.
-The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility ' s policy were to change.
-The second notice must be provided to the resident, and if applicable the resident ' s representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident ' s representative in cases where the facility was unable to notify the representative. The notice must provide information to the resident that explains the duration of bed-hold, if any, and the reserve bed payment policy. It should also address permitting the return of residents to the next available bed.

Review of facility "Bed Hold Policy" dated 3/4/25, indicated, "In accordance with federal and state guidelines, patients who are hospitalized or absent from the facility at midnight are entitled to hold their bed."

Review of the clinical record indicated Resident R6 was readmitted to the facility on 1/1/25.

Review of Resident R6's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/28/25, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), anxiety, and depression. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of "03."

Review of a progress note dated 3/16/25, at 3:32 a.m. indicated, "CNA (nurse aide) heard noise come from resident's room, found her sitting on the floor up against her bed, feet out in front of her, shoes on, bleeding from hematoma on right forehead. Pressure dressing applied, Ice pack to right side of face/forehead. Observed large hematoma, bubbled, and draining profusely. LOC (level of consciousness) WNL (within normal limits), resident stated I fell right there, I need to go to the hospital." "Left facility enroute to [hospital emergency room] at 3:15 a.m."

Further review of Resident R6's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R6 or the resident representative upon transfer.

Review of the clinical record indicated Resident R89 was admitted to the facility on 4/10/20.

Review of Resident R89's MDS dated 4/1/25, included diagnoses Alzheimer ' s disease (a type of brain disorder that causes problems with memory, thinking and behavior) and high blood pressure. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of "99," meaning that Resident R89 was so cognitively impaired to be unable to complete the interview. Review of a previous MDS assessment dated 10/17/24, also revealed a BIMS score of "99."

Review of a progress note dated 12/23/24, at 2:51 p.m. indicated, "Residents son, [second emergency contact] was informed [Resident R89] has been admitted to [hospital] with a dx of UTI (urinary tract infection)."

Further review of Resident 89's clinical record failed to reveal notation that the written notice of bed hold notification was provided to the Resident R89 or the resident representative upon transfer.

Review of the clinical record indicated Resident R123 was readmitted to the facility on 1/1/25.

Review of Resident R123's MDS dated 5/5/25, included diagnoses of chronic obstructive pulmonary disease (COPD, a group of progressive lung disorders characterized by increasing breathlessness) and cancer. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of "99," meaning that Resident R89 was so cognitively impaired to be unable to complete the interview.

Review of a progress note dated 12/26/24, at 1:13 p.m. indicted, "Alerted by staff that pt (patient) was off her baseline. Pt assessed and found lying in bed. Lethargic and barely arousable. Per staff, pt is usually OOB (out of bed) and at the nurse ' s station at this time." "MD (doctor of medicine) notified and ordered pt sent to ER (emergency room) for eval."

Review of a progress note dated 1/1/25, at 7:34 p.m. indicated, "Pt is admitted from [hospital] with diagnosis of RSV (Respiratory syncytial virus, causes infections of the respiratory tract).

Further review of Resident 123's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R123 or the resident representative upon transfer.

Review of the clinical record indicated Resident R138 was admitted to the facility on 2/3/25.

Review of Resident R138's MDS dated 2/10/25, included diagnoses of falls, ileus (inability of the intestine (bowel) to contract normally and move waste out of the body), and muscle wasting. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of "07."

Review of a progress note dated 2/8/25, at 1:00 a.m. Pt's nurse went to give her scheduled Tylenol 1000 mg in her bedroom, patient pushed nurse in her right breast away and into tv stand, patient became belligerent, cursing at staff, appears paranoid, making statements that she is going to call the police on staff, she is going to kill staff, staff is trying to kill her, patient stated she was going to have staff buried with her, aggressive, yelling a loud on dementia unit, RN registered nurse supervisor (RNS) was called up to unit, [RNS] and [nurse aide] were trying to redirect her/talk to her, unsuccessful, her daughter was called/put on speaker-patient refused to speak with her, supervisor explained above situation to daughter, daughter explained patient has had 3 alcoholic drinks or more a day prior to coming here, patient picked up a large/heavy pill crusher tried to throw it at me and [nurse aide], tried to hit us with it, we were able to take it away from her however she picked up the laptop and tried to use that to hit us, received permission from daughter to send out for evaluation, police officer arrived and [emergency services]came to pick her up, patient went with them willingly to [hospital] for evaluation."

Further review of Resident 138's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R138 or the resident representative upon transfer.

A request to review facility documents on 5/14/25, of the facility's compliance in notifying the State Ombudsman Office revealed the facility failed to provide documented evidence of notifying the State Ombudsman Office of resident transfers and discharges for the time period of 11/2023 through 4/2025.

A review of information on 1/2/25, provided by the State Ombudsman Office revealed that the facility failed to notify the State Ombudsman Office of transfers and discharges as required since 11/2023.

During an interview on 5/15/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for four of six residents reviewed for hospitalization and failed to report resident transfers and discharges to the State Ombudsman Office for a two year period from 11/2023 through 4/2025, as required.

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

28 Pa Code: 201.29(f)(g) Resident rights.


 Plan of Correction - To be completed: 06/10/2025

For Residents R6, R89, R123, and R138, retrospective written notification of the bed-hold policy was issued to the residents' representatives, accompanied by an explanation and apology for the oversight. All resident records were updated to reflect this communication. No adverse outcomes were reported as a result of the missing documentation. For the failure to notify the State Ombudsman Office, the facility submitted a backlog of required notifications covering November 2023 through April 2025 to the Ombudsman Office on May 16, 2025.

A facility-wide audit was conducted for all residents transferred or discharged between January 1 and May 15, 2025, to verify issuance of bed-hold notices and Ombudsman notifications. Any missing notifications will be issued retroactively.

The administrator will educate nursing staff and business office employees on obtaining written notification of the bed-hold policy on transfer. The regional director of nursing will educate social services on proper monthly state ombudsman notification for transfers.

The business office director or designee will audit notification of bed hold policy 2 times a week for four weeks, weekly for two weeks, then determined by QAPI thereafter. The Social Services Director or designee will maintain a submission log for all Ombudsman notifications and submit monthly compliance reports to the Administrator and QA Committee.

All corrective actions will be completed by June 10, 2025.
483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

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

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.
Observations:
Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to make certain that medications were properly stored and/or disposed of in two of three medication rooms (First and Second floor medication rooms) and two of five medication carts (MedBridge A-hall, MedBridge B-hall).

Finding include:

Review of facility policy "Storage and Expiration Dating of Medications, Biologicals" dated 3/4/25, stated that medications and biologicals that have an expired date on the label, have been retained longer than recommended by manufacturer or supplier guidelines are stored separate from other medications until destroyed or returned to the pharmacy or supplier. The policy further stated that multiple dose injectable vials and ophthalmics, once opened, require an expiration date shorter than the manufacturer ' s expiration date to insure medication purity and potency.

Review of the facility provided document, "Medications with Shortened Expiration Dates" indicated Aplisol (solution used in skin-testing for tuberculosis): Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency.

Review of prescribing information for cyanocobalamin (Vitamin B12) injections dated 5/23/14, indicated that "Any unused portion should be used within 30 days of opening."

During an observation of the second-floor medication room on 5/12/25, at 10:35 a.m. the following was observed:
-(1) vial of Aplisol, open and undated.
-(1) vial of Aplisol, dated as opened on 1/26/25.
-(1) vial of cyanocobalamin solution, open and undated.
-(1) bottle of liquid gabapentin, open and undated.
-(22) vacutainers with an expiration date of 1/31/25.
-(4) IV start kits with an expiration date of 7/31/24.
-(1) IV start kit with an expiration date of 10/31/24.
-(1) IV start kit with an expiration date of 3/31/25.
-(10) IV start kits with an expiration date of 4/30/25.
-(1) Blood collection set with an expiration date of 1/31/23.

During an interview on 5/12/25, at 10:42 a.m. Registered Nurse (RN) Employee E3 confirmed the above items were either undated or expired.

During an observation of the second-floor medication room on 5/12/25, at 10:50 a.m. the following was observed:

-(1) IV start kit with an expiration date of 7/31/24.
-(2) IV start kits with an expiration date of 10/31/24.
-(1) IV start kit with an expiration date of 3/31/25.
-(3) IV catheters with and expiration date of 8/1/23.
-(2) IV catheters with and expiration date of 8/1/24.
-(1) Huber infusion set with an expiration date of 11/30/24.

During an interview on 5/12/25, at 11:01 a.m. the Assistant Director of Nursing confirmed the above items were expired.

During an observation of the MedBridge A-hall medication cart on 5/13/25, at 8:12 a.m. the following was observed:
-One container of MedPlus Vanilla , appeared unopened, dated 4/21/25.

During an interview on 5/13/25, at 8:14 a.m. RN Employee E1 confirmed that nourishment shake must be labeled with date opened and is only to be used for 24 hours and then disposed of.
Employee E1 confirmed the above observations of container being labeled with date of 4/21/25 and was unopened.

During an observation of the MedBridge B-hall medication cart on 5/13/25, at 8:22 a.m. the following was observed:
-One container of MedPlus Vanilla, opened, partially used, and dated 5/10/25.

During an interview on 5/13/25, at 8:23 a.m. RN Employee E2 when asked the appropriate process after opening a container stated it is to be labeled with that date and used for 24 hours.
Employee E2 confirmed that the above observation of container being labeled with date of 5/10/25, was partially used and was still sitting on her cart when she started medication administration.

During an interview on 5/14/25, at approximately 2:40 p.m. the Nursing Home Administrator and Assistant Director of Nursing confirmed that the facility failed to make certain that our of date medications were properly stored and/or disposed of in two of three medication rooms and two of five medication carts.

28 Pa Code: 201.14 (a) Responsibility of licensee.

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

28 Pa Code: 211.9 (a)(1) Pharmacy services.

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


 Plan of Correction - To be completed: 06/20/2025

On May 16, 2025, all expired, undated, or improperly stored items were immediately removed from the facility med rooms and medication carts. This included expired IV supplies, undated vials, and nourishment supplements beyond use timeframes. Staff directly involved were counseled, and a full inventory sweep was completed the same day to ensure no other expired or undated items were present.

A full facility-wide audit of all medication rooms and medication carts was conducted on May 19, 2025. Any expired or improperly stored medications and supplies were discarded.

No residents experienced harm as a result of the items found. Nurses were instructed not to administer any nourishment or medication from undated or expired packaging.

The DON and ADON's will educate nurses on expiration guidelines for multi-dose vials (e.g., tubersol, insulin, etc.), 24-hour discard policies for nourishment supplements like MedPlus, labeling and storage requirements per facility policy and pharmacy guidance. Facility policy "Storage and Expiration Dating of Medications, Biologicals" was reviewed and revised to include clear definitions of responsibility for labeling, dating, and discarding.

The DON, ADON's, or designee will conduct random audits of all med rooms and 3 carts weekly for 4 weeks and then monthly for an additional 2 months, checking for compliance with dating, labeling, and expiration requirements.

All corrective actions will be completed by June 20, 2025.
483.20(g)(h)(i)(j) REQUIREMENT Accuracy of Assessments:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.20(g) Accuracy of Assessments.
The assessment must accurately reflect the resident's status.

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

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

§483.20(j) Penalty for Falsification.
§483.20(j)(1) Under Medicare and Medicaid, an individual who willfully and knowingly-
(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or
(ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment.
§483.20(j)(2) Clinical disagreement does not constitute a material and false statement.
Observations:
Based on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set ( MDS - periodic assessment of resident care needs) assessments accurately reflected the resident's status for two of eight residents (Resident R30 and R50).

Findings include:

The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated the following instructions:

-Section I: Active Diagnoses, that a diagnosis should be checked if they had had an active diagnosis for a disease or condition in the last seven days.
-Section O: Special Treatments, Procedures, and Programs: Review the resident ' s medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the assessment period.

Review of the admission record indicated Resident R30 was admitted to the facility on 6/25/24.

Review of Resident R30's MDS dated 4/3/25 included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and a psychotic disorder.

Review of the psychiatric evaluation dated 5/13/25 revealed diagnoses of adjustment disorder and unspecified dementia with behavioral disturbances.

During an interview on 5/15/25, at 10:01 a.m. the Assistant Director of Nursing (ADON)confirmed that adjustment disorder and dementia are not types of psychotic disorders, confirmed that Resident R30 has not been diagnosed with a psychotic disorder, and that the MDS was coded inaccurately.

Review of the admission record indicated Resident R50 was admitted to the facility on 3/31/24.

Review of Resident R50's MDS dated 4/23/25 included diagnoses of dementia, malnutrition, and osteoporosis (condition when the bones become brittle and fragile). Review of Section O: Special Treatments, Procedures, and Programs indicated Resident R50 received hospice services.

Review of physician orders dated 11/21/24, and reordered on 2/4/25, and 4/24/25, revealed Resident R50 received hospice services while in the facility.

Review of an MDS assessment completed on 2/7/25, indicated that Resident R50 did not receive hospice services.

During an interview on 5/15/25, at 10:01 a.m. the ADON confirmed that Resident R50 had continuously received hospice services and that the MDS assessment was completed inaccurately on 2/7/25.

During an interview on 5/15/25, at approximately 2:45 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure that MDS assessments accurately reflected the resident's status for two of eight residents.

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



 Plan of Correction - To be completed: 06/10/2025

For Resident R30, the MDS dated 4/3/25 was modified to remove the incorrect psychotic disorder diagnosis. Diagnoses were corrected to reflect only those supported by clinical documentation, including dementia with behavioral disturbances and adjustment disorder. For Resident R50, the MDS dated 2/7/25 was modified to accurately reflect the receipt of hospice services. Physician orders and hospice documentation were reviewed to confirm consistent service delivery during the assessment period. Facility documentation has been updated to ensure accuracy.

The facility reviewed MDS submissions from the prior 60 days for all current residents receiving a diagnosis of psychotic disorder and hospice services. This audit identified no further inaccuracies.

Administrator educated MDS nurses on section I and section O coding criteria.

The MDS nurses will audit all MDS assessments weekly for four weeks to ensure coding accuracy, with emphasis on sections I and O, then determined by QAPI thereafter.

All corrective actions will be completed by June 10, 2025.
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 facility policy, clinical records, and staff interview, it was determined that the facility failed to notify resident representatives of a transfer to the hospital for one of five residents (Resident R89).

Findings include:

Review of the facility policy, "Change in Condition Notification" dated 3/4/25, indicated the facility will "will promptly notify the resident's family or designated representative of any significant change in the resident's physical, mental, or psychosocial condition. Notification will occur as soon as possible and no later than 24 hours from the time the change is identified."

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status ("BIMS"), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of the clinical record indicated Resident R89 was admitted to the facility on 4/10/20.

Review of Resident R89's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/1/25, included diagnoses Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior) and high blood pressure. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of "99," meaning that Resident R89 was so cognitively impaired to be unable to complete the interview. Review of a previous MDS assessment dated 10/17/24, also revealed a BIMS score of "99."

Review of Resident R89's demographic profile indicated the son as the first emergency contact, daughter-in-law as the second emergency contact, and an additional son also as a second emergency contact, durable power of attorney, and resident representative.

Review of the "Change in Condition Evaluation" form initiated 12/23/24, at 5:05 a.m. revealed all sections of the form to be blank.

Review of the "Transfer to Hospital" form initiated 12/23/24, at 5:06 a.m. revealed under the section "Code Status" that for the question: Resident/Patient Decision Making Capacity, Resident R89 required a proxy to make her decisions. Under the section "Resident Representative" that Resident R89 was the resident representative contacted, that she was her caregiver and the next of kin, was notified of the transfer, and aware of the clinical situation.

Review of a progress note dated 12/23/24, at 2:51 p.m. indicated Residents son, [second emergency contact] was informed Resident R89 has been admitted to [hospital] with a diagnosis of a urinary tract infection.

Further review of Resident R89's progress notes failed to reveal documentation that Resident R89's emergency contacts were notified of the change in condition leading to Resident R89 being transferred to the hospital or the actual transfer to the hospital.

During an interview on 5/15/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to notify resident representatives of a transfer to the hospital for one of five residents.

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

28 Pa. Code 201.29(d) Resident rights.

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

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


 Plan of Correction - To be completed: 06/10/2025

The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein.

Resident R89 has since returned from the hospital. Upon identification of the issue, the facility immediately contacted the resident's designated representative and provided a full update regarding the transfer, treatment received, and current condition. Nursing staff were re-educated on the correct identification of cognitively impaired residents and the requirement for contacting the appropriate representative during all changes in condition and transfers.

A comprehensive review of all residents with a BIMS score of 12 or lower was conducted to identify any additional residents for whom proper notification may not have occurred that admitted within the last 30 days. No other instances of failure to notify a representative were identified.

DON and ADON's will educate nursing staff on proper timely notification for transfers to the hospital and changes in condition.

The Director of Nursing or designee will conduct an audit 3 times a week for 4 weeks of all hospital transfers and significant changes in condition to ensure timely and appropriate notification was made and documented.

All corrective actions will be completed by June 10, 2025.
483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:
Based on review of clinical records, and staff interview it was determined that the facility failed to provide appropriate treatment and care for one of four residents (Resident R21)

Findings include:

Review of the Resident Assessment Instrument 3.0 User's Manual effective October 2024, indicated that a Brief Interview for Mental Status ("BIMS"), is a screening test that aides in detecting cognitive impairment. The BIMS total score suggests the following distributions:
13-15: cognitively intact
8-12: moderately impaired
0-7: severe impairment

Review of the admission record indicated Resident R21 was admitted to the facility on 5/30/24.

Review of Resident R21's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/23/25, included diagnoses dementia (a group of symptoms that affects memory, thinking and interferes with daily life), muscle weakness and wasting, and a seizure disorder. Review of Section C: Cognitive Patterns indicated Resident R89 had a BIMS score of "99," meaning that Resident R21 was so cognitively impaired to be unable to complete the interview.

Review of a previous MDS assessment dated 3/5/25, also revealed a BIMS score of "99." Review of Section G: Functional Abilities indicated that Resident R21 required substantial/maximal assistance with bathing, upper and lower body dressing, putting on or taking off footwear, and personal hygiene.

Review of Resident R21 ' s care plan for skin integrity indicated, "Observe skin condition daily with ADL (activities of daily living) care and report any abnormalities.

Review of the nurse aide task list revealed that the skin observation tool is only completed as needed and was not completed on any day in March 2025.

Review of Resident R21 ' s Treatment Administration Record (TAR) for March 2025, indicated Resident R21 was ordered weekly skin checks to be done on Wednesdays with her showers. Review of the skin check completed on 5/19/25, by Licensed Practical Nurse (LPN) Employee E4 failed to indicate that any skin alteration was noted.

Review of Resident R21 ' s progress notes from 5/19/25, through 5/23/25, failed to reveal documentation that any wounds were noted or reported on Resident R21 ' s ankles.

Review of a progress note dated 3/23/25, at 5:00 p.m. indicated, "This nurse was approached by the patient's daughter, to tell me that her mother has wounds on her right outer ankle and inner aspect of the left leg and there is no dressing on them. This nurse went to assess the areas in question, I found that both areas are old, dry and scabbed over, the scab on the rt. (right) ankle is measuring 1.5 cm x 0.5 cm and the one Lt. (left) leg is 0.3 cm x 0.3 cm. Daughter voiced that "this is not new", I agree with her that, it is not new, is already dry and scabbed over and putting a dressing will make it moist and she agreed."

Review of a progress note dated 3/28/25, at 12:49 p.m. indicated, "When nurse went to complete scheduled wound care on the RLE (right lower extremity) scabbed area, nurse noticed that sock to the RLE (right lower extremity) has a fresh blood stain. Upon removing the sock and assessing the skin, nurse noted a new skin tear measuring 1.3 cm x 0.3 cm that appears to have been caused by the wheel chair foot pedals." "When questioned as to how she sustained the skin tear, pt (patient) could not explain how she got a skin tear to the RLE.

During an interview on 5/15/25, at approximately 11:00 a.m. the Assistant Director of Nursing confirmed that Resident R21 ' s wound should have been observed during bathing, dressing, and hygiene assistance by staff prior to the wounds having healed enough for scabbing to have formed, and additionally should not have required family member observations to discover the wounds.

During an interview on 5/15/25, at 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide appropriate treatment and care for one of four residents.

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

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


 Plan of Correction - To be completed: 06/14/2025

For Resident R21, both wounds were assessed on 3/23/25 and determined to be dry and scabbed over. Preventative wound care protocols were implemented immediately upon discovery.

A whole house audit will be conducted to ensure no other unidentified wounds are discovered. Treatments will be immediately implemented in the event a new wound is observed.

DON and ADON's will educate all nurse aides who were re-educated on skin integrity responsibilities during ADLs, dressing, and bathing. Nurses will be educated by the DON and ADON on proper weekly head-to-toe skin checks and accurate documentation.

The wound nurse will audit 10 residents weekly to verify that skin checks were completed and documented by licensed nurses. She will also audit timely interventions for any new wounds discovered.

All corrective actions will be completed by June 14, 2025.
§ 201.19(5) LICENSURE Personnel policies and procedures.:State only Deficiency.
(5) Records relating to a medical exam, if required by a facility, or attestation that the employee is able to perform the employee ' s job duties.

Observations:
Based on review of employee personnel records and staff interview, it was determined that the facility failed to ensure newly hired employees had an attestation that the employee can perform his/her job duties for five out of five personnel files reviewed, prior to employment (Employees E5, E6, E7, E8, and E9).

Findings include:

Review of the personnel files for Employees E5, E6, E7, E8, and E9 revealed the following:

Nurse Aide E5 was began employment on 3/11/25. While a statement that Nurse Aide Employee E5 was free from communicable diseases was present, no physical exam or attestation that he/she can perform his/her job duties was present.

Nurse Aide Employee E6 was began employment on 2/24/25. While a statement that Nurse Aide Employee E6 was free from communicable diseases was present, no physical exam or attestation that he/she can perform his/her job duties was present.

Nurse Aide Employee E7 was began employment on 2/24/25. While a statement that Nurse Aide Employee E7 was free from communicable diseases was present, no physical exam or attestation that he/she can perform his/her job duties was present.

Dietary Aide Employee E8 was began employment on 3/6/25. While a statement that Dietary Aide Employee E8 was free from communicable diseases was present, no physical exam or attestation that he/she can perform his/her job duties was present.

Administrative Employee E9 was began employment on 3/11/25. While a statement that Administrative Employee E9 was free from communicable diseases was present, no physical exam or attestation that he/she can perform his/her job duties was present.

During an interview on 5/16/25, at 2:45 p.m. the Nursing Home Administrator confirmed that the facility failed to ensure newly hired employees had an attestation that the employee can perform his/her job duties for five out of five personnel files reviewed, prior to employment.


 Plan of Correction - To be completed: 06/10/2025

For Employees E5, E6, E7, E8, and E9, retrospective attestations confirming their ability to perform the duties of their respective job positions were obtained and placed in each personnel file. Each employee underwent supervisory observation of task performance to ensure capability, and no limitations were noted.

A full audit of all active employee personal files will be completed to ensure every file contains a communicable disease clearance and a signed attestation or physician exam verifying ability to perform job duties. Any missing attestation will be completed.

The Administrator will educate HR on regulatory requirements for personal files, including the need for physician capability attestation as a condition of employment.

The human resource director or designee will audit all new employee files weekly for 4 weeks to ensure compliance with all pre-employment health documentation requirements.

All corrective actions will be completed by June 10, 2025.

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