Pennsylvania Department of Health
MOSSER NURSING HOME
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MOSSER NURSING HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey completed on May 21, 2025, it was determined that Mosser Nursing Home 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:

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

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

§483.20(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 clinical record review and staff interview, it was determined that the facility failed to complete an accurate Minimum Data Set (MDS) assessment for two of 12 sampled residents. (Residents 19 and 29)

Findings include:

Clinical record revealed that Resident 19 had diagnoses that included cognitive communication deficit and major depressive disorder. Review of the MDS assessment dated April 14, 2025, revealed that Sections C (the Brief Interview for Mental Status) and D (the Mood assessment/interview) were incomplete.

Clinical record review revealed that Resident 29 had diagnoses that included dementia and nontraumatic intracranial hemorrhage (bleeding within the brain in the absence of trauma or surgery). On December 21, 2024, the physician ordered that the facility provide hospice services. Review of the MDS assessment dated March 30, 2025, revealed no documentation that resident had hospice services in place during the review period. The MDS assessment inaccurately reflected that the resident was not receiving hospice services.

In an interview on May 21, 2025, at 12:50 p.m., the Registered Nurse Assessment Coordinator (RNAC) confirmed that Resident 19's and 29's MDS assessments were inaccurate.

Plan of Correction - To be completed: 07/11/2025

Resident 19's MDS was coded as directed by the RAI manual. The data entry error for Resident 29 was corrected, transmitted and accepted on 5/21/2025 at 10:07am.

All residents' current MDS will be audited for accurate coding of hospice services and the completion of BIMS and Mood interviews.

Staff responsible for coding the MDS and performing interviews will be educated on coding related to hospice services and completion of interviews.

The RNAC or designee will audit residents' MDS for accurate coding of hospice services and completion of interviews weekly for four weeks and then monthly for three months. All audits will be tracked quarterly through the Quality Assurance Performance Improvement Committee.

483.25 REQUIREMENT Quality of Care:

§ 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 facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 12 sampled residents. (Resident 7)

Findings include:

Review of the policy entitled, "Medication Administration," last reviewed January 31, 2025, revealed staff was to obtain vital signs if necessary, and document in the medical record the physician ordered medication administration information.

Clinical record review revealed that Resident 7 had diagnoses that included atrial fibrillation (an irregular heartbeat), chronic kidney disease, and hypertensive retinopathy (damage to the retina caused by chronic high blood pressure). On July 15, 2024, the physician ordered staff to administer a blood pressure medicine (metoprolol tartrate) twice a day. Staff was not to administer the medication if the heart rate was less than 60 beats per minute or if the resident's systolic blood pressure (the first measurement of blood pressure when the heart beats and the pressure is at its highest) was less than 110 millimeters of mercury (mm/Hg). Review of Resident 7's April and May 2025 Medication Administration Records revealed that staff administered or held the medication 86 times with no documentation that the heart rate and blood pressure were assessed prior to medication administrating or holding of the medication per physician's order.

In an interview on May 21, 2025, at 10:30 a.m., the Director of Nursing confirmed there was no documented evidence that the heart rate or the blood pressure were taken prior to medication administrating or holding of the medication per physician's order and they should have been there for Resident 7.

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

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

Plan of Correction - To be completed: 07/11/2025

Resident 7's orders were updated immediately to prompt recording of vital signs per the parameters of the order.

All residents' medication orders were audited for necessary supplemental documentation.

All nursing staff will be educated regarding medication orders with parameters and necessary documentation.

The DON or designees will audit new medication orders for necessary supplemental documentation weekly for four weeks and then monthly for three months. All audits will be tracked quarterly through the Quality Assurance Performance Improvement Committee.

483.25(c)(1)-(3) REQUIREMENT Increase/Prevent Decrease in ROM/Mobility:

§483.25(c) Mobility.
§483.25(c)(1) The facility must ensure that a resident who enters the facility without limited range of motion does not experience reduction in range of motion unless the resident's clinical condition demonstrates that a reduction in range of motion is unavoidable; and

§483.25(c)(2) A resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

§483.25(c)(3) A resident with limited mobility receives appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is demonstrably unavoidable.

Observations:

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to implement interventions to prevent further decline and/or improve range of motion for one of two sampled residents with limited range of motion. (Resident 26)

Findings include:

Clinical record review revealed that Resident 26 had diagnoses that included dementia, muscle weakness, and other abnormalities of gait and mobility. The Minimum Data Set (MDS) assessment dated February 12, 2025, indicated that the resident had cognitive impairment and was dependent on staff for personal hygiene and dressing. Review of the physical therapy progress note dated February 11, 2025, indicated that resident had limited range of motion to his right foot. On March 3, 2025, the physician ordered that staff apply a MAFO (molded ankle foot orthosis-a custom made brace that provided support and control) in Velcro closure sneakers to be worn at all times on the right foot when Resident 26 was out of bed. Observations on May 20, 2025, at 10:30 a.m. and 12:11 pm, and on May 21, 2025, at 9:00 a.m., revealed that Resident 26 was in his wheelchair without the MAFO brace on.

In an interview on May 21, 2025, at 10:58 a.m., the Therapy Director confirmed that the resident was identified with a contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of his right foot, and that the MAFO brace should have been on when the resident was observed.

Plan of Correction - To be completed: 07/11/2025

Resident 26's MAFO was applied to his right foot per orders on 5/21/2025.

All residents will be audited for the presence of ordered positioning devices.

All nursing staff will be educated on the application of positioning devices.

Compliance with positioning device applications will be audited weekly for four weeks and then monthly for three months. All audits will be tracked quarterly through the Quality Assurance Performance Improvement Committee.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:

§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.71 and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.

Observations:

Based on policy review, observation, and staff interview, it was determined that the facility failed to administer medications in a manner that prevents the spread of infections on one of two nursing units. (West Wing)

Findings include:

Review of the facility policy entitled, "Infection Control Plan: Standard Precautions," last reviewed January 31, 2025, revealed that gloves should be worn whenever exposure to the mucus membranes (soft tissue that lines the body's canals and organs, such as the eye) is planned or anticipated.

On May 20, 2025, at 9:11 a.m., Licensed Practical Nurse (LPN) 1 was observed administering medications to Resident 33. The nurse applied Ocusoft lid scrubs to the eyes of the resident with her ungloved hands.

In an interview on May 21, 2025, at 9:30 a.m., the Director of Nursing confirmed that the nurse should have been wearing gloves to administer medications around the eyes.

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

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

Plan of Correction - To be completed: 07/11/2025

Resident 33 did not have any adverse effects.

All licensed nursing staff will be educated on ophthalmic medication and treatment administration, including infection control considerations.

The DON or Designee will conduct medication administration audits of ophthalmic medications and treatments weekly for four weeks and then monthly for three months. All audits will be tracked quarterly through the Quality Assurance Performance Improvement Committee.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of nursing time schedules, it was determined that the facility failed to meet the minimum nurse aide (NA) to resident ratios for one of 21 days reviewed.

Findings include:

Review of nursing schedules for 21 days from November 24 through November 30, 2024, March 23 through March 29, 2025, and May 14 through May 20, 2025, revealed the following:

The facility failed to meet the minimum NA to resident ratio of one NA for 15 residents on night shift (11:00 p.m. to 7:00 a.m.) on November 29, 2024.

Plan of Correction - To be completed: 07/11/2025

The facility will ensure the minimum Nurse Aide staff to resident ratio is provided on each shift.

The Scheduler will be re-educated to ensure the minimum Nurse Aide staff to resident ratio is provided on each shift.

Audits will be conducted weekly for four weeks and monthly for three months to ensure the minimum Nurse Aide staff to resident ratio is provided on each shift.

All audits will be tracked quarterly through the Quality Assurance Performance Improvement Committee.

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