Pennsylvania Department of Health
TRANSITIONS HEALTHCARE ALLENS COVE
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

TRANSITIONS HEALTHCARE ALLENS COVE
Inspection Results For:

There are 90 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.


TRANSITIONS HEALTHCARE ALLENS COVE - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights survey and a complaint survey completed on May 9, 2024, it was determined that Transitions Healthcare Allen's Cove was not in compliance with the following requirements of 42 CFR Part 483 Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

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

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

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

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

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

Observations:
Based on clinical record review and staff interview, it was determined that the facility failed to provide notice of transfer to the Office of the State Long-Term Care Ombudsman, after a transfer out of the facility, for four of four residents reviewed for hospitalization (Residents 10, 14, 26 and 57).

Findings include:

Review of Resident 10's clinical record revealed diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should be) and hypertension (high blood pressure).

Further review of Resident 10's clinical record revealed that she was transferred and admitted to the hospital on March 30, 2024.

During an interview with the Nursing Home Administrator (NHA) on May 9, 2024, at 10:10 AM, he stated that the Office of the State Long-Term Care Ombudsman was not notified of Resident 10's transfer to the hospital.

Review of Resident 14's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe) and Multiple Sclerosis (MS- a disease in which the immune system eats away at the protective covering of nerves).

Further review of Resident 14's clinical record revealed that she was transferred and admitted to the hospital on January 10, 2024.

During an interview with the Nursing Home Administrator (NHA) on May 8, 2024, at 10:37 AM, he stated that the Office of the State Long-Term Care Ombudsman was not notified of Resident 14's transfer to the hospital.

Review of Resident 26's clinical record revealed diagnoses that included stage 4 pressure ulcer of the sacrum (injury to skin and underlying tissue resulting from prolonged pressure on the skin; Stage 4 is full-thickness skin and tissue loss) and hypertension (elevated blood pressure).

Further review of Resident 26's clinical record revealed that he was transferred and admitted to the hospital on April 22, 2024.

During an interview with the NHA on May 8, 2024, at 10:37 AM, he stated that the Office of the State Long-Term Care Ombudsman was not notified of Resident 26's transfer to the hospital.

Review of Resident 57's clinical record review revealed diagnoses included dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), and ileus (a painful obstruction of the intestine).

Further review of Resident 57 clinical record documented admitted to the facility on February 17, 2024, and was transferred to the hospital on February 22, 2024, due to a change in condition.

During an interview with Nursing Home Administrator on May 8, 2024, at 2:00PM with the Nursing Home Administration it was revealed that the facility hadn't notified the State Ombudsman of Resident 57's transfer.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa Code 201.18(b)(3) Management

Plan of Correction - To be completed: 06/21/2024

1. The NHA or designee will submit three prior months or more if requested of transfers to the Office of Long Term Care Ombudsman email.
2. The DON or designee will supply the monthly transfer log to correct email address as required by the 5th of each month for the month prior effective June 1 2024 for May 2024 data and ongoing.
3. Education was provided by the Regional clinical nurse to the NHA and DON on this regulation. The submission of this data has been added to the monthly QAPI minutes as a visual reminder to submit,
4. An audit will be conducted monthly x4 by the NHA or designee to ensure monthly submissions are sent timely. Results will be taken to the QAPI committee for review of findings and further interventions if warranted.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observation, review of facility policy, and interview it was determined that the facility failed to store and serve food/beverages in accordance with professional standards for food safety in the kitchen area and one of one nourishment pantry.

Findings include:

Review of facility policy Food Storage, dated 2021, read, in part, all stock must be rotated with each new order received, old stock will be utilized first. Food should be dated as it is placed on the shelves. All storage containers or storage bas must be accurately labeled and dated. Leftover food must be used within seven days or discarded as per the 2017 Federal Food Code.

Observation in the dry store room on May 6, 2024, at 9:25 AM one half package of pasta was open and not securely closed.

During an interview with Employee 5, Food Service Director, on May 6, 2024, at 9:25 AM it was revealed that the past should've been securely closed.

Observation in the walk-in refrigerator on May 6, 2024, at 9:30 AM one container of thirty hard boiled eggs was not securely closed or date marked, one 25 pound container hard boiled eggs was open and not date marked when opened.

During an interview with Employee 5, on May 6, 2024, at 9:30 AM it was revealed that the eggs should've been securely closed, and date marked.

Observation in the walk-in freezer on May 6, 2024, at 9:42 AM one plastic bag with six beef hamburgers, one-five pound bag chicken breasts, and one-five pound bag of pork sausage were not date marked.

During an interview with Employee 5, on May 6, 2024, at 9:42 AM it was revealed that the aforementioned bags of meat should've been date marked.

Observation in the nourishment pantry freezer on May 6, 2024, at 9:53 AM two 1.5 quart containers of vanilla ice cream and 2 boxes of chocolate coated vanilla ice cream cones weren't labeled with a resident identifier and weren't date marked.

Observation in the nourishment pantry refrigerator on May 6, 2024, at 9:56 AM one-32 ounce vanilla fortified nutritional shake, two-32ounce butter pecan fortified nutritional shakes were open with contents removed and not date marked with an open date, and one plastic thermal bowl of tomato soup was not date marked.

During an interview with Employee 5, on May 6, 2024, at 9:56 AM it was revealed that the ice cream in the freezer doesn't belong to the facility and should be marked with a resident identifier and date marked, the fortified shakes should be date marked when opened, and the soup shouldn't have been stored in the refrigerator it should've been discarded after meal service.

During an interview with the Nursing Home Administrator on May 8, 2024, at 1:30 PM concerns regarding food storage of the aforementioned items were noted, and no further information was provided.

28 Pa code 211.6 - Dietary Services

Plan of Correction - To be completed: 06/21/2024

1. All food not stored properly was discarded.
2. Dietary manager educated dietary staff on proper storage of food.
3. Dietary manager will educate nursing staff on proper labeling and dating of food items in the event they would have to perform this task.
4. An audit will be performed to make sure all food is being stored and dated properly in the pantry, walk in refrigerator, dry storage area and freezer three times weekly x 4 weeks, then two times monthly x 2 months. Results will be taken to QAPI for review of findings and further interventions if warranted.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Plan of Correction - To be completed: 06/21/2024

1. Residents identified for O2 and or nebulizer equipment had orders verified and entered into the MAR/TAR as ordered. In addition, equipment was changed, dated and bagged if required.
2. The DON or designee will complete a baseline audit patient that are utilizing nebulizers and oxygen to ensure that appropriate orders, that tubing is dated and bagged, surfaces are cleaned after nebulizer usage and if required that distilled water is dated and not located within the patients' room.
3. Education will be provided to the nursing staff regarding ensuring proper orders, dated tubing, and bagging equipment are identified when completing the MAR/TAR.
4. Education will be provided to nursing staff regarding the cleaning of surfaces where respiratory equipment is stored.
4. The DON or designee will audit as indicated in the baseline audit three times weekly x 4 weeks, then two times monthly x 2 months.
5. Results will be taken to the QAPI for review of findings and further interventions if warranted.

483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance:

§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 the dietary extension sheets (guidelines as to what foods should or should not be served for specific therapeutic diets), the Diet Type facility report and staff interview it was determined that the facility failed to provide a therapeutic diet per physician's order, for four residents on a Renal/ low potassium diet (a diet aimed at keeping levels of fluids, electrolytes, and minerals balance in the body in individuals who's kidneys don't function as they should or who receive treatments to remove excess water, solutes and toxins from the blood due to kidney failure) and 18 residents on a Consistent Carbohydrate diet (CCD- meals are planned to provide a consistent amount of carbohydrates day to day.) out of 22 residents reviewed on a therapeutic diets.

Findings include:

On May 8, 2024, review of facility report Diet Type, printed May 8, 2024; documented the following therapeutic diet were prescribed: eighteen residents were ordered consistent carbohydrate diet, and four residents were ordered a renal/low potassium. The in house census on May 8, 2024, was 55 residents.

Review of extension sheets (a guide as to what items are t0 be served each meal basted on diet order) documented the following diets: regular, dysphagia advanced (bite sized foods that are moist), and puree (very smooth, crushed, of blended food). No therapeutic diets were documented on the extension sheets.

Review of facility diet manual, Maryland Department of Health and Mental Hygiene Diet Manual for Long Term Care Residents, revised 2014, read, in part, low potassium diet should avoid the following foods and beverages: bananas, prunes and prune juice, orange Juice, baked potatoes and sweet potatoes, tomatoes, tomato juice, vegetable juice. Liberalized Renal Diet follow low potassium guidelines, limit obviously salted foods/meats: sausage, bacon, scrapple, ham, chipped beef, corned beef, hot dogs, canned meats, potato chips, salty snack foods, pickles, olives, sauerkraut.

Further review of the facility diet manual read, in part, a CCD diet is designed for residents with diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). Meals are planned to provide a consistent amount of carbohydrates day to day. Carbohydrates are distributed consistently per three meals and include an evening snack. Often portions of regular desserts are small so that the menu doesn't exceed the allowed amount of carbohydrates or calories.

During an interview with Employee 5, Food Service Director on May 7, 2024, at 2:30 PM it was revealed that the facility doesn't offer a Renal, or CCD diet and therefore the therapeutic diet isn't documented on the extension sheets.

Surveyor informed Employee 5 that there are physician orders for Renal, and CCD diets. Employee 5 stated that tomato products and pork products are limited on a renal diet, and the CCD diets receive sugar free jelly and maple syrup, and a sugar substitute. It was also noted that these restrictions would be verbally communicated to the dietary staff.

During an interview with the Nursing Home Administrator on May 8, 2024, at 2:00 PM it was revealed that the facility should follow physician ordered therapeutic diets, and facility approved therapeutic diets should be documented on menu extension sheets as a guide for dietary personnel to provide appropriate menu items for each physician prescribed diet.

28 Pa. Code 211.12(d)(3) Nursing services
28 Pa Code 211.6(a) - Dietary Services

Plan of Correction - To be completed: 06/21/2024

1. Resident's cited diets were reviewed by the dietician to ensure proper nutritional needs are met.
2. The facility dietician, DON and dietary manager met to establish diet extension protocol for the facility.
3. Nursing and dietary staff educated on diet extension protocol.
4. Resident audit was performed to make sure the residents were on the correct diet per the diet extension protocol. Ongoing audits will be performed weekly for 4 weeks, then monthly x 2 months. Results of the audit will be taken to QAPI for review of findings are further interventions if warranted.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident:

§483.24(c) Activities.
§483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Observations:

Based on resident interviews, staff interviews, and facility document review, it was determined that the facility failed to provide an ongoing activities program designed to meet the physical, mental and psychosocial well-being for five out of five residents who attended group for Resident Council (Resident 2, 13, 39, 51, and 260).

Findings include:

An interview with Employee 3 on May 7, 2024, at 11:30 AM, revealed that the facility only has one activity staff member who works Monday through Friday, and that they do not hold activities for residents on weekends.

Interviews with resident's during a group interview on May 8, 2024, at 9:00 AM, revealed the facility does not have any activities held on weekends for the residents, that scheduled activities sometimes get cancelled, and that the resident's feel the activity director needs help.

Review of the facility's Resident Council Meeting Minutes from March 2024 revealed the following comments regarding activities: Activities have gone downhill. The activities director has not been here, residents are left alone in dayroom. Aides are in the room, on their phone. Left to watch movies. Can we get volunteers? No activities have been done in a month.

Review of the facility's Resident Council Meeting Minutes from April 2024 revealed the following comments regarding activities: Activities director needs help. Residents left in day room all the time with movies on. Would like to have volunteer program. More outdoor activities/areas for outdoor use.

Review of the facility's Activity Calendar for March 2024, April 2024, and May 2024 revealed there are no activities scheduled on the calendars for Saturdays or Sundays.

During an interview with the Nursing Home Administrator on May 9, 2024, at 10:08 AM, he confirmed there are no activities scheduled on weekends, and that the Activity Director works from Monday through Friday.

28 PA Code 201.29 (j) Resident Rights
28 PA Code 211.10 (d) Resident Care Policies

Plan of Correction - To be completed: 06/21/2024

1. The facility NHA or designee will meet with the resident council to determine activities that the residents would like to have within the facility.
2. The facility NHA or designee will wok with the Activity Director to investigate the utilization of outside resources and the possibility of a volunteer program to enhance the activity calendar to include weekends.
3. The NHA or designee will engage other departments to assist with enhancing the activity calendar to broaden the range of provided activities (i.e. cooking class with the dietary manager)
4. An audit will be conducted by the NHA or designee weekly x 4 and monthly x 2 to ensure that activities are occurring as posted and that residents are satisfied with the programming.
5. Results of the audit will be taken to QAPI for review of findings are further interventions if warranted.

483.24(a)(1)(b)(1)-(5)(i)-(iii) REQUIREMENT Activities Daily Living (ADLs)/Mntn Abilities:

§483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that:

§483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ...

§483.24(b) Activities of daily living.
The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living:

§483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care,

§483.24(b)(2) Mobility-transfer and ambulation, including walking,

§483.24(b)(3) Elimination-toileting,

§483.24(b)(4) Dining-eating, including meals and snacks,

§483.24(b)(5) Communication, including
(i) Speech,
(ii) Language,
(iii) Other functional communication systems.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure one of two residents reviewed for activities of daily living was provided care and services in regard to hygiene and bathing (Resident 32).

Finding include:

Review of Resident 32's clinical record revealed diagnosis that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypoxemia (low levels of oxygen in the blood).

During an interview with Resident 32 on May 6, 2024, at 10:35 AM, she revealed that she didn't get washed up the previous morning (May 5, 2024).

Review of Resident 32's clinical record tasks revealed a restorative nursing program for activities of daily living (ADLs) for 15 minutes twice daily, that includes the resident washing and drying her face, hands, and upper body with mid-mod assist from staff and perform her grooming with set-up assist.

Review of Resident 32's clinical record revealed a Restorative Program Note written on March 8, 2024, at 4:41 PM, that stated the following: Resident continues to wash and dry her face, hands, and upper body with min-mod assist from staff and perform her grooming with set-up assist.

Further review of the ADL task revealed the following dates and times were marked Not Applicable, indicating it was not completed: January 16, 2024 at 11:59 AM, January 27, 2024 at 1:59 PM, January 28, 2024 at 8:37 AM, February 4, 2024 at 7:55 AM, February 10, 2024 at 12:09 PM, February 11, 2024, at 1:39 PM, February 17, 2024 at 1:18 PM, February 18, 2024 at 1:39 PM, February 24, 2024 at 1:39 PM, February 25, 2024 at 12:23 PM, February 26, 2024 at 6:46 AM, March 3, 2024 at 8:23 PM, March 17, 2024 at 12:19 PM, April 6, 2024 at 9:17 PM, April 13, 2024 at 5:06 PM, April 14, 2024 at 9:59 PM, and May 4, 2024 at 1:59 PM.

During an interview with the Director of Nursing on May 9, 2024, at 11:32 AM, he stated he did not have an answer as to why the dates listed above were marked Not applicable. The Nursing Home Administrator revealed he would have expected the resident's ADL tasks to have been completed.

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

Plan of Correction - To be completed: 06/21/2024

1. Facility cannot edit old documentation errors.
2. Facility will audit ADL documentation on other residents to identify any baseline opportunities.
3. DON or designee will provide education to the nursing supervisors on reviewing the ADL coding report prior to end of shift to ensure completion and accuracy and address concerns prior to end of shift.
4. DON or designee will provide education to all CNA's regarding ADL coding and accuracy of coding.
4. An audit will be conducted by DON or designee three times weekly x 4 weeks, then two times monthly x 2 months for ADL coding, results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.

483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:

This is a less serious (but not lowest level) deficiency and 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(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

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

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

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

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

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

Observations:

Based on observations, facility policy review and staff interview, it was determined that the facility failed to ensure each resident the right to a dignified existence during meal service for one of one dining rooms observed.

Findings Include:

Review of facility policy titled "Resident Rights", with a revision date of May 5, 2023, revealed "Provide meals to all Residents at each table at the same time."

Observation in the dining room during lunch on May 6, 2024, at 12:59 PM, revealed Residents 6, 10, 17, 30 and 50 all sitting at a table. Resident 50 was observed to be eating her lunch, while Residents 6, 10, 17 and 30 had not yet been served their lunch.

Additional observations revealed the following:
At 1:04 PM, Resident 30 was served her lunch.
At 1:08 PM, Resident 6 was served her lunch.
At 1:12 PM, Resident 17 was served her lunch.
At 1:25 PM, Resident 10 was served her lunch.

Further observations in the dining room during lunch on May 6, 2024, revealed there were 19 residents total eating in the dining room. Observations revealed all 19 residents were eating their lunch served on trays.

Observation in the dining room on May 8, 2024, at 12:28 PM, revealed 22 residents in the dining room. All 22 residents were eating their lunch served on trays.

During an interview with the Nursing Home Administrator (NHA) and Director of Nursing on May 8, 2024, at 1:46 PM, the NHA stated that residents should be provided meals at the same time and should not be served meals on trays.

28 Pa Code 201.29(a) Resident Rights

Plan of Correction - To be completed: 06/21/2024

Preparation and or evaluation of the following plan of correction set forth in this document does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and or executed solely because it is required by the provisions of federal and state law.

1. Facility is unable to go back in time to serve R 6,10,17,30 and 50. No negative outcome was identified because of not serving residents at the same time.
2. No other residents were identified as not being served together when in a group setting.
3. The facility will initiate a seating chart to ensure that trays are passed based on the chart, and ensure all residents are served at the same time.
4. Education will be provided by the Dietary manager or designer to staff serving residents to ensure residents are served per table at the same time and that plates are removed from the serving tray.
5. An audit will be conducted by the dietary manager/designee to ensure that residents seated together are served at the same time without trays three times weekly x 4 weeks then two times monthly x 2 months. Results will be taken to the QAPI committee for review of findings are further interventions if warranted.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:

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

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

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

Observations:

Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to provide residents with a copy of the facility's bed-hold policy as a result of a transfer out of the facility for three of four residents reviewed for hospitalization (Residents 10, 14 and 26).

Findings Include:

Review of facility policy titled "Bed Holds and Returns and Therapeutic Leave of Absence", revised September 28, 2022, revealed "The Facility will provide information on bed hold requirements to all residents upon admission and again at time of transfer from the Facility. Bed Hold requirements will be included in the Facility Admission packet to be reviewed during the admission process and will be considered the first notice of the Facility Bed Holds and Returns policy...The second notice, which details the duration of the bed hold policy, will be issued at the time of transfer. In cases of emergency transfer, notice 'at the time of transfer' means that the family, surrogate, or representative are provided with written notification within 24 hours of the transfer."

Review of Resident 10's clinical record revealed diagnoses that included chronic kidney disease (a condition in which the kidneys are damaged and cannot filter blood as well as they should be) and hypertension (high blood pressure).

Further review of Resident 10's clinical record revealed that she was transferred and admitted to the hospital on March 30, 2024.

During an interview with the Nursing Home Administrator (NHA) on May 9, 2024, at 10:10 AM, he stated that the bed hold notice was not provided to Resident 10 or her responsible party upon her transfer to the hospital.

Review of Resident 14's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe) and Multiple Sclerosis (MS- a disease in which the immune system eats away at the protective covering of nerves).

Further review of Resident 14's clinical record revealed that she was transferred and admitted to the hospital on January 10, 2024.

During an interview with the Nursing Home Administrator (NHA) on May 8, 2024, at 10:43 AM, he stated that Resident 14 was an automatic 15 day bed hold under Medicaid, and therefore, was not provided the bed hold notice upon transfer to the hospital.

Review of Resident 26's clinical record revealed diagnoses that included stage 4 pressure ulcer of the sacrum (injury to skin and underlying tissue resulting from prolonged pressure on the skin; Stage 4 is full-thickness skin and tissue loss) and hypertension (elevated blood pressure).

Further review of Resident 26's clinical record revealed that he was transferred and admitted to the hospital on April 22, 2024.

During an interview with the NHA on May 8, 2024, at 2:11 PM, he stated that the bed hold notice was not provided to Resident 26 or his responsible party upon his transfer to the hospital.

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

Plan of Correction - To be completed: 06/21/2024

1. The facility will review the current residents out to the hospital for bed hold policy and issue if this has not already been completed.
2. Any current residents moving forward will have a bed hold policy provided.
3. A copy of the bed hold policy as well as the bed hold agreement will be placed in the front of all resident hard charts. If a resident must be transferred the facility form will be completed in person or via phone if required with the original provided to patient or responsible party and a copy to remain in the chart.
4. DON or designee will provide education to the nursing staff on the proper procedure for issuing the bed hold notice.
5. DON or designee will audit all transfers three times weekly x 4 weeks, the two times monthly x 2 months to ensure that the proper bed hold policy is initiated and executed. Results will be taken to the QAPI committee for review of findings and further interventions if warranted.

483.20(g) REQUIREMENT Accuracy of Assessments:

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

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that the resident assessment accurately reflected the resident's status for two of 17 residents reviewed (Resident 21 and 32).

Finding include:

Review of Resident 21's clinical record contained diagnosis that included: dementia (a condition characterized by progressive loss of intellectual functioning, impairment of memory and abstract thinking), Parkinson's disease (disorder of the central nervous system that affects movement), moderate protein calorie malnutrition (moderately-malnourished, protein and energy intake doesn't meet nutritional needs), and psychosis (a severe mental condition in which thought and emotions are so affected that contact is lost with external reality).

Further review of Resident 21's clinical record on May 6, 2024, at 12:46 PM documented that Resident 21 had been on Hospice services since November 15, 2023.

Review of Resident 21's quarterly Minimum Data Set (MDS- part of the federally mandated process for clinical assessment of all Medicare and Medicaid certified nursing homes) dated February 7, 2024, failed to documented resident received hospice services.

During an interview with the Director of Nursing on May 9, 2024, at 9:05 AM it was revealed the Resident had a physician's order for hospice services with a start date of November 14, 2023, an end date of November 19, 2023, and therefore the order fell off the physician orders.

May 9, 2024, at 10:00 AM the facility provided an amended quarterly MDS that included hospice services for Resident 21.

During an interview with the Nursing Home Administrator on May 9, 2024, at 11:00PM it was noted the concern regarding hospice services not documented on Resident 21's quarterly MDS dated February 7, 2024; no further information was provided.

Review of Resident 32's clinical record revealed diagnosis that included chronic respiratory failure (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body) and hypoxemia (low levels of oxygen in the blood).

Observation of Resident 32 on May 6, 2024, at 11:35 AM and May 7, 2024, at 1:19 PM, revealed that Resident 32 was using oxygen running at 2 liters. Further interview with Resident 32 on May 7, 2024, at 1:19 PM, revealed that she uses oxygen daily.

Review of Resident 32's clinical record revealed a nurse's progress note on February 26, 2024, at 9:39 PM, that included the following text: Resident continues on oxygen as previous with no shortness of breath noted; and another note on February 28, 2024, at 9:44 AM, that included the following text: Resident continues on oxygen.

Review of Resident 32's quarterly MDS dated February 29, 2024, revealed that Section O0110 C1. Oxygen was marked 'No' indicating that Resident 32 has not used oxygen while a resident during the lookback period.

During an interview with the Director of Nursing and the Nursing Home Administrator on May 9, 2024, at 10:13 AM, revealed that oxygen should have been marked Yes on Resident 32's February 29, 2024, MDS and that a modification MDS has been completed to reflect that.

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

Plan of Correction - To be completed: 06/21/2024

1. R21 and R32 MDS were corrected with accurate coding and resubmitted with modifications.
2. The regional care mix manager will complete education with the LPNAC on accurate coding of identified sections of MDS per RAI guidelines and appropriate coding with emphasis on accurate coding for hospice and oxygen.
3. An initial audit of MDS's will be completed for the past 30 days on identified residents. The Licensed Practical Nurse Assessment Coordinator will complete all assessments. LPNAC / Designee will complete an audit of MDS submission three times weekly x 4 weeks, then two times monthly x 2 months. An RN will verify accuracy of MDS prior to submission, including accurate coding in Section O. An RN will make any corrections needed prior to submission.
4. The results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan:

§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

§483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan-
(i) Is developed within 48 hours of the resident's admission.
(ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section).

§483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to:
(i) The initial goals of the resident.
(ii) A summary of the resident's medications and dietary instructions.
(iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.
(iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a baseline care plan that included the minimum healthcare information necessary to properly care for a resident was developed and implemented within 48 hours of admission for one of 17 residents reviewed (Residents 261)

Findings include:

During an interview with Resident 261 on May 7, 2024, at 9:00 AM it was revealed that she resided in Personal Care prior to hospitalization and then admission into skilled nursing care on May 3, 2024. It was also revealed she had been on hemodialysis (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer preform these functions naturally) for some time, and received hemodialysis on Monday, Wednesday, and Friday outside of the nursing facility.

Review of resident 261's clinical record documented diagnoses that included protein calorie malnutrition (moderately-malnourished, protein and energy intake doesn't meet nutritional needs), dependence on hemodialysis, and diabetes mellitus (the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine).

Review or Resident 261's physician orders failed to document an order for hemodialysis, or care needs surrounding hemodialysis.

Review of Resident 261's baseline care plan failed to document hemodialysis and the required care surrounding dialysis.

During an interview with the Nursing Home Administrator on May 8, 2024, at 2:00 PM it was revealed that hemodialysis, and resident care surrounding dialysis should've been included in the baseline care plan.

28 Pa. Code 211.12(d) Nursing Services

Plan of Correction - To be completed: 06/21/2024

1. Resident R32's care plans and orders were updated to reflect her use of hemodialysis.
2. An audit will be conducted on any other resident on dialysis to ensure proper orders and care plans are in place.
3. The DON or designee will provide education to nursing staff regarding updating care plans for dialysis treatments and required care surrounding dialysis treatment.
4. DON or designee will audit dialysis orders and care plans 3 times weekly x 4 weeks, then two times monthly x 2 months to ensure accuracy. The results of the audit will be taken to the QAPI committee for review of findings and further interventions if warranted.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on clinical record review and resident and staff interviews, it was determined that the facility failed to provide routine drugs to its residents and ensure procedures to assure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one of 17 residents reviewed (Resident 111).

Findings Include:

Review of Resident 111's clinical record revealed diagnoses that included chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe) and obstructive sleep apnea (intermittent airflow blockage during sleep).

During an interview with Resident 111 on May 6, 2024, at 10:20 AM, she stated that she wants her nicotine patch but is still waiting for it. She said she was told that the facility has not yet received it.

Review of Resident 111's clinical record revealed an order for a Nicotine patch, with a start date of May 1, 2024, apply one patch once a day for smoking cessation.

Review of Resident 111's medication administration record (MAR), dated May 2024, revealed that on May 1, 2, 3, 4 and 5, the Nicotine patch is signed off with a "9", meaning other/see nurse's note. On May 6, 2024, the Nicotine patch is signed off with a "5", meaning medication not administered/see nurse notes.

Review of the corresponding nursing notes revealed the following regarding the Nicotine Patch:
May 1- No corresponding note
May 2- Medication "unavailable"
May 3- Medication "unavailable-on order from pharmacy"
May 4- Medication "on order"
May 5- Medication "on order"
May 6- Pending delivery from pharmacy.

Medication administration observation on May 7, 2024, at 9:02 AM revealed Employee 4 (Licensed Practical Nurse) applying Resident 111's nicotine patch.

During an interview with the Director of Nursing on May 9, 2024, at 9:29 AM, he stated that nicotine patches are on the list of medications that the pharmacy won't send unless there is an over the counter (OTC) authorization form completed. He stated that nicotine patches are not a house stock medication and there was a delay in nursing staff completing the OTC authorization form, resulting in a delay with pharmacy sending the medication.

28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(3) Management
28 Pa. Code 211.9(a)(1) Pharmacy services
28 Pa. Code 211.12 (d)(2)(3)(5) Nursing services

Plan of Correction - To be completed: 06/21/2024

1. Nicotine patches were procured for R111.
2. A baseline audit indicates no other patient needed nicotine patches.
3. Nicotine patches are on the house stock list and will be available on demand. Education will be provided by the DON or designee to the central supply coordinator on the procurement of nicotine patches as house stock
4. DON or designee will audit any new orders for nicotine patches three times weekly x 4 weeks, then two times monthly x 2 months to ensure that staff utilize house stock. Results will be taken to QAPI for review of findings and further interventions if warranted.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp:

§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance;

§483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature.

Observations:

Based on observation, review of facility policy, and resident and staff interviews, it was determined that the facility failed to provide food and beverage that are at a safe and appetizing temperature for one of one meal observed on the South unit.

Findings include:

Review of facility policy Hazard Analysis Critical Control Points and Food Safety, dated 2021, read, in part, staff will recognize potentially hazardous foods such as milk, and milk products, poultry, shell eggs, and meat and handle them carefully. The Director of Food Service and Registered Dietitian should determine the appropriate temperature ranges for the food service operation. The United States Department of Health and Human Services Food Code uses 41 degrees Fahrenheit for cold foods and 135 degrees for hot foods.

Review of resident council meeting minutes for February 8, 2024, and March27, 2024, documented resident concern with cold food. Resident interviews during the initial pool process revealed concerns with the temperature of the food and beverages during meal service.

Test tray completed on May 6, 2024, on south unit included maple glazed fish, egg noodles, carrots, cake, coffee, and milk. The coffee and milk temperatures were unsatisfactory; 134 degrees Fahrenheit, and 51 degrees Fahrenheit.

During an interview with Employee 6, Dietary Aide, on May 6, 2024, at 1:30 PM it was revealed that the coffee should be 140 degrees Fahrenheit, and the milk should be 40 degrees Fahrenheit.

During an interview with Employee 5, Food Service Director, on May 6, 2024, at 1:40 PM it was revealed that there isn't a test tray form or policy for food temperatures at point of service.

During an interview with the Nursing Home Administrator on May 8, 2024, at 1:30 PM concerns regarding beverage temperatures during meal service on May 6th were noted and it was revealed that May 6th was the first day the main dining room was closed for renovations and all residents were served on meal trays.

28 Pa code 211.6 - Dietary Services

Plan of Correction - To be completed: 06/21/2024

Facility reviewed the process to keep milk at or below 41 degrees and coffee above 135 degrees. New process put in place with deeper pans for ice to place milk. New coffee machine to hold temperature.
1. Dietary staff educated.
2. Dietary manager will provide education to nursing staff to ensure proper temperatures for milk (at or below 41 degrees) and coffee (above 135 degrees)
5. Audit performed to ensure coffee and milk are served at the proper temperature will be done three times weekly x 4 weeks, then two times monthly x 2 months. Results will be taken to QAPI for review of findings and further interventions if warranted.

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