§483.10(g)(4) The resident has the right to receive notices orally (meaning spoken) and in writing (including Braille) in a format and a language he or she understands, including: (i) Required notices as specified in this section. The facility must furnish to each resident a written description of legal rights which includes - (A) A description of the manner of protecting personal funds, under paragraph (f)(10) of this section; (B) A description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources under section 1924(c) of the Social Security Act. (C) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and informational agencies, resident advocacy groups such as the State Survey Agency, the State licensure office, the State Long-Term Care Ombudsman program, the protection and advocacy agency, adult protective services where state law provides for jurisdiction in long-term care facilities, the local contact agency for information about returning to the community and the Medicaid Fraud Control Unit; and (D) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community. (ii) Information and contact information for State and local advocacy organizations including but not limited to the State Survey Agency, the State Long-Term Care Ombudsman program (established under section 712 of the Older Americans Act of 1965, as amended 2016 (42 U.S.C. 3001 et seq) and the protection and advocacy system (as designated by the state, and as established under the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) (iii) Information regarding Medicare and Medicaid eligibility and coverage; (iv) Contact information for the Aging and Disability Resource Center (established under Section 202(a)(20)(B)(iii) of the Older Americans Act); or other No Wrong Door Program; (v) Contact information for the Medicaid Fraud Control Unit; and (vi) Information and contact information for filing grievances or complaints concerning any suspected violation of state or federal nursing facility regulations, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, non-compliance with the advance directives requirements and requests for information regarding returning to the community.
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Observations:
Based on review of facility policy, observations, resident interviews, and staff interviews, it was determined that the facility failed to post the State Survey Agency phone number and contact information, readily accessible on two of two nursing floors. (1st Floor, 2nd Nursing Units)
Findings Include:
Review of facility policy titled, Resident Rights with a revision date of August 31, 2022 states, "Purpose: Ensures residents know that they can lodge complaints without reprecussions."
During an observation of First Floor nursing units on May 20, 2025 at 11:00 a.m. revealed there was no posting for the required Department of Health contact information. A tour of the lobby area revealed there was a standard size page for the contact information for Department of Health but the phone number was outdated in between the exterior door of the lobby and the interior glass door of the lobby.
Resident Council meeting was held on May 22, 2025, at 10:30 a.m. on the first floor with nine awake, alert, and oriented residents. Several residents reported that they were not aware of where the information on how to contact the State Department of Health is in the building. (R50, R74, R78, R93).
A tour was taken with the Director of Social Services, Employee E12 Observation of the First Floor Nursing unit with the Employee E12 on May 22th at 1:05 p.m. to look for required notices and postings. A tour of the first floor (bottom floor) nursing unit revealed there were no required Department of Health contact information posted. The Director of Social Services, Employee E12 showed the surveyor a clear plastic covering next to the elevator that did not have a paper in it and stated, "it is usually here, but we have one resident and sometimes he takes the paper".
The tour of the second floor (top floor) revealed there was another clear plastic covering next to the elevator that did not have a paper in it. Further review of floor revealed there was one posted size posting for the Department of Health but it was written in Spanish. The Director of Social Services Employee E12 confirmed 2:03 p.m. that there were no postings for the required Department of Health contact information in English on either on the nursing units (first floor or second floor).
Interview with the Nursing Home Administrator Employee E1 on May 22, 2025 at 2:09 p.m. confirmed that there was no posting for the Department of Health contact information in English in the facility due to renovations of the bathrooms over the weekend and the signs had been taken down.
28 Pa. Code: 201.18(a)(e)(1) Management
28 Pa. Code: 201.18(b)(1) Management
| | Plan of Correction - To be completed: 06/18/2025
Preparation and submission of this Plan of Correction does not constitute an admission or agreement with the facts alleged or conclusions stated in the Statement of Deficiencies. This Plan of Correction is submitted solely because it is required by Federal and State regulations.
1. Social Services Director posted updated signs at high traffic area's including but not limited to, both first and second floor nursing units in the facility with the State Survey Agency Phone number and contact information. 2. Administrator / Designee conducted house wide audit to ensure up to date signage is posted in high traffic areas. 3. Administrator / Designee will educate Staff on Requirements to Furnish Residents with Information and contact information for filing grievances or complaints with the State Survey Agency. 4. Administrator / Designee will conduct audits weekly x 4 and monthly x 2 to ensure that signs remain visible and legible. Results to be brought to facility QAPI meeting, for further evaluation and recommendations.
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