Pennsylvania Department of Health
 AVENTURA AT TERRACE VIEW
Patient Care Inspection Results

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Minimal Citation - No Harm Minimal Harm Actual Harm Serious Harm
AVENTURA AT TERRACE VIEW
Inspection Results For:

There are  199 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.
AVENTURA AT TERRACE VIEW - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, Abbreviated Complaint Survey, and Civil Rights Compliance Survey completed on March 28, 2025, it was determined that Aventura at Terrace View 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:


483.25(b)(1)(i)(ii) REQUIREMENT Treatment/Svcs to Prevent/Heal Pressure Ulcer:This is a more serious deficiency but is isolated to the fewest number of residents, staff, or occurrences. This deficiency results in a negative outcome that has negatively affected the resident's ability to achieve his/her highest functional status.
§483.25(b) Skin Integrity
§483.25(b)(1) Pressure ulcers.
Based on the comprehensive assessment of a resident, the facility must ensure that-
(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and
(ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Observations:

Based on observations, select facility policy, facility investigative reports, a review of clinical records, and staff interviews it was determined the facility failed to consistently provide care and services to prevent the development and promote healing of a pressure sore resulting in harm for one resident (Resident 93) out of 24 sampled residents.

Findings include:

According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer (a localized area of skin damage that develops when prolonged pressure is applied to the body) best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address areas of risk.

ACP (The American College of Physicians is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e., support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair.

A review of facility policy entitled "Pressure Ulcer/Injury Care and Management" last reviewed January 22, 2025, revealed residents will receive care consistent with professional standards of practice, to prevent pressure ulcer/injury unless the individual's clinical condition demonstrates they were unavoidable. Residents will receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. Residents with a pressure ulcer will have wound measurements weekly by the physician or registered nurse. Observation of the wound should be completed with each dressing change and should include at a minimum:

A.Location and staging
B.Size, depth, the presence and location of any undermining or tunneling
C.Exudate if present the type, color, odor, and amount
D.If pain is present the nature and frequency
E.Wound bed to include the color and type of tissue
F.Description of the wound edges

A review of Resident 93's clinical record revealed admission to the facility on May 1, 2024, with diagnoses, which included radiculopathy (a condition where the nerve roots become compressed or irritated. This compression or irritation can lead to pain, numbness, tingling, weakness), hypotension (low blood pressure), and peripheral vascular disease (a group of conditions that affect the blood vessels outside the heart and brain, primarily in the legs).

A review of a Quarterly Minimum Data Set assessment dated February 3, 2025, (MDS - a federally mandated standardized assessment process completed periodically to plan resident care) revealed the resident was moderately cognitively impaired and was at risk for developing pressure ulcers.

A review of a quarterly Braden scale for predicting pressure sore risk assessment dated February 21, 2025, revealed the resident responds to verbal commands but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits the ability to feel pain or discomfort. The resident's ability to walk is severely limited or nonexistent and was at risk for pressure ulcers.

A review of the resident's plan of care for potential for skin breakdown related to decreased mobility initially dated May 1, 2024, revealed a goal that the resident will have no additional skin breakdown. Planned interventions included assist with bed mobility to prevent shearing (rubbing friction) of skin, provided incontinence care (the management and treatment of involuntary loss of urine or stool) and apply barrier cream (a topical product that forms a protective layer on the skin, shielding it from irritation and damage caused by prolonged contact with urine or feces) as ordered, and a pressure reducing device to the bed and chair.

A review of the "Documentation Survey Report" for February 2025 revealed that Resident 93 was incontinent daily, yet there was no documented evidence that incontinence care and barrier cream were provided with each episode of incontinence.

On February 26, 2025, at 10:15 PM, a facility investigative report revealed that Resident 93 was found to have an open area on the coccyx (bottom of the spine) measuring 2.5 cm x 2 cm. It was noted the area was cleaned and a dressing was applied. Further it was indicated the resident will be checked for incontinence and changed every two hours and as needed to prevent any further skin alterations.

A review of a Weekly Skin Observation completed on February 27, 2025, at 6:10 AM, Employee 1, a licensed practical nurse (LPN) documented that Resident 93 had moisture-associated skin damage (MASD) on the coccyx measuring 2.5cm x 2cm but failed to describe wound characteristics such as shape, color, and drainage.

There was no evidence that a registered nurse (RN) assessed the wound and provided documentation to the type of wound, location, size, color, odor, or drainage.

There was no documented evidence the resident had any treatment, or a dressing applied to the wound on the evening shift on February 26, 2025, after the wound was identified. Further there was no evidence that a treatment or dressing was applied or in place on the night shift on February 27, 2025, or the day shift on February 27, 2025.

A review of an onsite note dated February 27, 2025, at 3:58 PM by Employee 2 CRNP (certified registered nurse practitioner) revealed the resident was seen for a new open area to the coccyx. Employee 2 indicated the resident had a pressure ulcer of the sacral region (base of spine). No further assessment was documented of the wound. The employee indicated she wrote a new order for Zinc Oxide paste 20% apply to the coccyx every shift for wound care.

A review of the February 2025 Treatment Administration Record (TAR) revealed the first treatment to the resident's newly developed pressure ulcer wasn't completed until February 27, 2025, on the evening shift.

There was no documented evidence the facility implemented the two-hour check and change for Resident 93 to prevent further skin alterations.

A physician's order dated February 28, 2025 (two days after the wound was identified) directed that Resident 93 be turned and repositioned every two to three hours.

A review of the clinical record revealed the nurse aides who are responsible to turn and reposition the resident failed to document they were turning and repositioning the resident as indicated in the physician's order.

A review of the "Medication Administration Audit Report" for the month of February 2025 revealed the licensed staff were signing out once a shift that the resident was offered to be turned and repositioned. Further review indicted staff were signing off the turning and repositioning was completed for the entire shift prior to the task being completed.

A review of an "Initial Wound Evaluation and Management Summary" competed by the consultant wound practitioner dated March 3, 2025, noted it had deteriorated into an unstageable deep tissue injury (DTI a pressure injury where the full depth of tissue damage is obscured by slough, layer of dead, yellow or gray tissue that separates from the underlying healthy skin, or eschar, thick, dry crust of dead tissue that forms over a wound, making it impossible to determine the underlying stage). The wound now measured 9 cm x 6. 5cm and had a depth of 0. 2cm. The wound was noted to have a moderate amount of serosanguineous drainage (a type of fluid that is discharged from a wound which is a mixture of clear, watery fluid and blood). Plan of care recommendations included offload the wound and turn side to side in bed every one to two hours.

Despite recommendations to offload pressure and turn the resident side to side every 1-2 hours, facility documentation revealed that this intervention was never consistently implemented.

A review of the "Medication Administration Audit Report" for the month of March 2025 revealed the licensed staff were signing out once a shift that the resident was offered to be turned and repositioned. Further review indicted staff were signing off that the turning and repositioning was completed for the entire shift prior to the task being completed.

A review of a wound consultant note dated March 11, 2025, revealed an increased wound size to 9.5 cm x 7.5 cm x 0.6 cm, moderate serosanguineous drainage, and the wound bed was covered with thick necrotic tissue (dead, dry, black, leathery tissue that can cover a wound bed and hinders healing) all indications the wound had worsened rather than improved.

A review of a progress note dated March 12, 2025, at 5:28 PM revealed the resident was transported out of the facility to the hospital for progressive wound deterioration, abnormal lab values and signs of systemic infection.

A review of hospital documentation dated March 13, 2025, revealed Resident 93 was sent to the hospital for abnormal lab work and a progressive sacral wound. The resident stated at the hospital the wound was very painful. A CT scan (a medical imaging procedure that uses X-rays to create detailed, cross-sectional images of the body's internal structures, such as bones, organs, and blood vessels) was completed and confirmed a deep fissuring pressure ulcer penetrating the soft tissue. Sepsis (a life-threatening condition that occurs when the body's immune system overreacts to an infection, causing widespread inflammation and damage to multiple organs) secondary to the wound infection and a surgical consult was recommended.

Further Review of hospital paperwork revealed the resident had a surgical procedure on March 13, 2025. The resident's wound had a sharp excisional debridement (a method of wound care where a healthcare professional uses sharp instruments like scalpels, scissors, or curettes to remove dead or damaged tissue) down to the bone. On March 18, 2025, the resident required a diverting loop colostomy surgery (a surgical procedure that creates a temporary or permanent opening in the colon to divert fecal material away from a specific section). This procedure was only completed to divert fecal matter away from the wound on the resident's coccyx and promote healing.

An observation of the resident on March 25, 2025, at 10:00 AM revealed the resident was lying on his back and bottom in bed. The resident was not turned onto his side to offload the pressure on his wound.

An observation of the resident on March 25, 2025, at 1:45 PM revealed the resident was lying on his back and bottom in bed. The resident was not turned onto his side to offload the pressure on his wound.

An observation of the resident on March 26, 2025, at 8:56 AM revealed the resident was lying on his back and bottom in bed. The resident was not turned onto his side to offload the pressure on his wound. The resident appeared to be uncomfortable in bed. The resident arms were flailing around. Resident was mumbling but unable to identify what he was saying.

An observation of the resident on March 26, 2025, at 9:57 AM revealed the resident was lying on his back and bottom in bed. The resident was not turned onto his side to offload the pressure on his wound.

An observation of the resident on March 26, 2025, at 11:30 AM revealed the resident was lying on his back and bottom in bed. The resident was not turned onto his side to offload the pressure on his wound.

An observation of the resident on March 27, 2025, at 8:26 AM revealed the resident was lying on his back and bottom in bed. The resident was not turned onto his side to offload the pressure on his wound. The resident appeared to be uncomfortable in bed. The resident arms were flailing around. When asked if the resident was in pain he stated yes.

An observation of the resident on March 27, 2025, at 10:14 AM revealed the resident was lying on his back and bottom in bed. The resident was not turned onto his side to offload the pressure on his wound.

An observation of the resident on March 27, 2025, at 11:00 AM revealed the resident was lying on his back and bottom in bed. The resident was not turned onto his side to offload the pressure on his wound. Further observations revealed the incontinence pad underneath the resident was noted to be saturated with a yellow substance and the dressing was visibly wet. The resident's wound was observed with Employee 3 LPN and Employee 4 RN (registered nurse) and revealed a stage 4 pressure ulcer (the most severe, characterized by full-thickness tissue loss, exposing muscle, tendon, cartilage, or bone, and potentially leading to serious complications like infection) measuring 9. 5cm x 7 cm x 2cm. The wound bed appeared large and deep with a red beefy wound base with some slough noted in the middle.

An observation of the resident on March 28, 2025, at 8:36 AM revealed the resident was lying on his back and bottom in bed. The resident was not turned onto his side to offload the pressure on his wound. The resident appeared to be uncomfortable in bed. The resident arms were flailing around.

An interview with the Nursing Home Administrator and Director of Nursing on March 28, 2025, at approximately 1:45 PM confirmed the facility failed to develop and implement planned measures to prevent the development and promote healing of a pressure ulcer.


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

28 Pa. Code 211.18(b)(1) Management





 Plan of Correction - To be completed: 04/11/2025

Based on the comprehensive assessment of a resident, the facility ensures a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.
Resident # 93 was assessed by the facility's licensed wound care consultant. The alteration in skin integrity to the coccyx was noted to be stable. By 4/11/25, information was added to the Task to allow for documented evidence of incontinence care, barrier cream application after each episode of incontinence, and turning and repositioning.
By 4/11/25, the DON and/or designee reassessed other residents using the Braden Scale. By 4/11/25, the DON and/or designee reviewed and updated careplans accordingly for those residents determined to be at risk for pressure ulcer development. By 4/11/25, the DON and/or designee documented careplan changes and communicated those changes to direct care staff to ensure timely implementation of interventions. By 4/11/25, the DON and/or designee reviewed other residents to ensure assessment of other wounds by a registered nurse (RN) with documentation regarding the type, location, size, and color of the wound, as well as a description of any odor or drainage. By 4/11/25, the DON and/or designee reviewed other residents to ensure treatments were initiated after noting a wound. By 4/11/25, the DON and/or designee reviewed other at-risk residents to ensure the nurse aide implemented the two-hour check and change process to prevent further skin alterations. By 4/11/25, the DON and/or designee reviewed documentation for other at-risk residents to validate incontinence care and barrier cream are provided with each episode of incontinence. By 4/11/25, the DON and/or designee reviewed documentation for other at-risk residents to validate documentation of turning and repositioning. By 4/11/25, the DON and/or designee reviewed other residents to validate that preventive interventions are initiated consistently and documented accordingly for other residents.
By 4/11/25, the Temporary Manager educated Nurses and Nurse Aides on the provision of care and services necessary to prevent the development of and promote healing of pressure sores. Specifically, education was provided on the following: the need for the RN to assess a wound and to provide information regarding the type, location, size, and color of the wound, as well as a description of any odor or drainage; the need for the nurse to initiate a treatment after noting a wound; the importance of documenting evidence the nurse aide implemented the two-hour check and change process to prevent further skin alterations; the need to ensure documentation of incontinence care and barrier cream are provided with each episode of incontinence; the importance of documenting turning and repositioning; the importance of the nurse not signing off on the MAR that turning and repositioning is being completed for the entire shift prior to the task being completed; and on the importance of ensuring preventive interventions are initiated consistently and documented accordingly.
By 4/11/25, the DON and/or designee provided additional targeted in-service education and hands-on skills training to licensed nurses, including registered nurses (RNs) and licensed practical nurses (LPNs). This training focused on several key areas critical to effective pressure ulcer management: pressure ulcer prevention, staging and identification; turning and repositioning protocols; moisture management and incontinence care; and accurate wound documentation and treatment implementation. All training will be documented and validated for competency. No nurse will work until he/she receives targeted in-service education and hands-on skills training.
By 4/11/25, a licensed wound care consultant has been contracted to evaluate all current residents with pressure ulcers or skin integrity concerns. The consultant will be responsible for ensuring wound care interventions are individualized and consistently implemented. In addition, the consultant will oversee and validate weekly wound documentation and measurements. A progress report summarizing these findings and any identified issues must be submitted weekly to the facility's Quality Assurance and Performance (QAPI) committee.
By 4/11/25, the facility implemented a wound monitoring program that includes a comprehensive wound care tracking and monitoring log. This program will support the completion of weekly audits to confirm that skin and wound assessments are conducted in a timely and accurate manner, that physician orders and wound treatments are being followed as directed, and that turning and repositioning is being documented according to the resident's careplan. The results of these audits will be reviewed by the QAPI committee, and any deficiencies will be addressed with documented corrective actions on a weekly basis.
By 4/11/25, leadership oversight and accountability will be reinforced by requiring the Administrator and DON to provide direct supervision of pressure ulcer practices. They will submit a weekly signed attestation verifying that wound prevention and treatment practices are being consistently followed. Additionally, they will submit a written summary each week to the QAPI committee, detailing the audit findings, any deficiencies identified, and the actions taken to address those issues.
By 4/11/25, a Root Cause Analysis (RCA) was conducted with support from the QAPI committee to identify underlying system failures that contributed to the deficient practice. The findings of this analysis will be integrated into the facility's overall intervention plan to strengthen its pressure ulcer prevention and treatment program moving forward.
The DON and/or designee will audit 5 residents 3 times a week for 4 weeks, then 5 residents weekly for 4 weeks, then 5 residents twice a month to ensure the provision of care and services necessary to prevent the development and promote healing of pressure sores. Specifically, the following will be audited: (1) assessment of other wounds by a registered nurse (RN) with documentation present regarding the type, location, size, and color of the wound, as well as a description of any odor or drainage; (2) treatments are initiated after noting a wound; (3) implementation of the two-hour check and change process for applicable residents; (4) incontinence care and barrier cream provision with each episode of incontinence; (5) implementation of turning and repositioning; and (6) preventive interventions are initiated consistently and documented accordingly.
The results of audits will be presented to the QA&A Committee by the licensed wound care consultant and DON and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.60(i)(1)(2) REQUIREMENT Food Procurement,Store/Prepare/Serve-Sanitary:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(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 and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in the dietary department.

Findings include:

Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. You cannot always see, smell, or taste harmful bacteria that may cause illness according to the USDA (The United States Department of Agriculture, also known as the Agriculture Department, is the U.S. federal executive department responsible for developing and executing federal laws related to food).

The initial tour of the dietary department was conducted with the facility's Certified Dietary Manager (CDM)/Food Service Manager on March 25, 2025, at 9:25 AM, revealed the following unsanitary practices with the potential to introduce contaminants into food and increase the potential for food-borne illness, were identified:

Observations inside of the walk-in refrigerator revealed that there were three cooked meats that were each wrapped in clear plastic wrap with a bright green label that noted "deli d/c (discard).
Further observation revealed two brownish-pink colored cook meat that was sitting in a reddish liquid that was wrapped in plastic wrap, dated March 22, 2025, with a discard date of April 10, 2025, the CDM reported that it was cooked roast beef. Additionally, observed another whitish-tan colored meat wrapped in plastic wrap and dated March 22, 2025, with a discard date of April 10, 2025, the CDM reported that it was cooked ham. The CDM stated the items did not have the proper discard dates noted on the labels and the items should be discarded after seven days or March 29, 2025, and not April 10, 2025.

A review of a facility policy entitled "Food Storage and Retention Guide" last reviewed by the facility on January 22, 2025, indicated that ready-to-eat/prepared foods, in a form that is edible without additional preparation to achieve food safety (examples: leftovers, deli salads, cut produce) and stored in a refrigerator at less than or equal to 41 degrees Fahrenheit for up to seven days. Day one is the day of preparation.

Observations of the walk-in freezer, sections of the plastic strip air curtain were broken or missing, and ice buildup was observed on the floor. The damaged air curtain compromises temperature control and sanitation.

A ceiling tile above the three-compartment sink had a hole approximately 4.25 inches in diameter. This structural deficiency poses a risk of dust or debris falling into the sink area used for cleaning and sanitizing dishware and equipment.

Further observation of the dietary department revealed two doors, one leading into the dish room (used to bring in soiled meal carts) and another leading from the dish machine to the corridor (used for cleaned dishware), had peeling paint with rust underneath and failed to close properly. The disrepair impedes adequate separation of clean and dirty areas, increasing the risk of cross-contamination.

The above findings were confirmed during the tour of the dietary department with the CDM on March 25, 2025, at 10:15 AM, who acknowledged the conditions and confirmed the dietary department should be maintained in a sanitary manner to prevent the potential for food contamination and foodborne illness.

28 Pa. Code 201.18 (e) (2.1) Management

28 Pa. Code 211.6 (f) Dietary Services




 Plan of Correction - To be completed: 04/11/2025

The facility ensures food is stored, prepared, distributed and served in accordance with professional standards for food service safety.
During the survey, on 3/25/25, the Dietary Manager immediately discarded the three cooked meats.
By 4/11/25. the Dietary Manager replaced the plastic strip curtain in the walk-in freezer.
On 3/25/25, the Dietary Manager addressed the ice buildup on the walk-in freezer floor.
By 4/11/25, the Maintenance Director replaced the ceiling tile above the three-compartment sink.
By 4/11/25, the Maintenance Director addressed the peeling paint and rust underneath the door leading into the dish room and the door leading from the dish machine to the corridor. By 4/11/25, the Maintenance Director addressed both doors so that they close properly.
By 4/11/25, the Dietary Manager inspected the kitchen for other potential food storage concerns, potential compromised temperature control and sanitation concerns and potential items in disrepair that could impede adequate separation of clean and dirty areas. Issues were addressed accordingly.
By 4/11/25, the contracted dietary service provider educated Cooks and Dietary Aides on the importance of ensuring food is stored, prepared, distributed and served in accordance with professional standards for food service safety. The policy was also reviewed at this time.
The Dietary Manager and/or designee will inspect the kitchen 5 times a week for 4 weeks, then once a week for 4 weeks, then twice a month for one month to monitor compliance with professional standards for food service safety.
The results of audits will be presented to the QA&A Committee by the Dietary Manager and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.71(a)(1)(3)(b)(1)(c)(1)-(5) REQUIREMENT Facility Assessment:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.71 Facility assessment.
The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.

§483.71(a) The facility assessment must address or include the following:
§483.71(a)(1) The facility's resident population, including, but not limited to:
(i) Both the number of residents and the facility's resident capacity;
(ii) The care required by the resident population, using evidence-based, data-driven "methods" that considering the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments as required under § 483.20;
(iii) The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population;
(iv)The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

§483.71(a)(2) The facility's resources, including but not limited to the following:
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non- medical);
(iii) Services provided, such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies;
(iv) All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

§483.71(a)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach as required in §483.73(a)(1).

§ 483.71(b) In conducting the facility assessment, the facility must ensure:
§ 483.71(b)(1) Active involvement of the following participants in the process:
(i) Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and
(ii) Direct care staff, including but not limited to, RNs, LPNs/LVNs, NAs, and representatives of the direct care staff, if applicable.
(iii) The facility must also solicit and consider input received from residents, resident representatives, and family members.

§483.71(c) The facility must use this facility assessment to:
§483.71(c)(1) Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required in § 483.35(a)(3).

§483.71(c)(2) Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population.

§483.71(c)(3) Consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population.

§483.71(c)(4) Develop and maintain a plan to maximize recruitment and retention of direct care staff.

§483.71(c)(5) Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care.
Observations:

Based on staff interviews and a review of facility documentation, it was determined the facility failed to timely review and update its facility-wide assessment to identify the specific needs of residents, including those with dementia and behavioral health needs. The facility also failed to develop and maintain a plan to maximize recruitment and retention of direct care staff, which is necessary to ensure care for the current resident population.

At the time of the survey ending March 28, 2025, the most recent documented facility-wide assessment was dated July 15, 2024. While the assessment included general population data, it failed to reflect changes in the resident population and staffing levels, including those required to care for the 39 residents on the locked D1 Dementia/Memory Care Unit and the 21 residents on the C1 Male Behavioral Health Unit.

The assessment failed to describe the facility's specific strategies or resources needed to care for residents with dementia, Alzheimer's disease, and behavior-related diagnoses.

The assessment tool provided to the survey team on March 25, 2025, did not include the activity needs or psychosocial needs of residents residing in the specialty units (D1 and C1).

No documentation was found indicating a dedicated or tailored activities program or corresponding budget for these units. As a result, the facility failed to demonstrate it had the capacity to meet the unique needs of residents with cognitive and behavioral health diagnoses.

A review of the January 23, 2025, state survey indicated previous citations related to inadequate services for residents with dementia and behavioral health needs. Despite this, the facility's assessment was not updated to reflect needed improvements or resource allocation to address these findings.

The facility assessment did not include a documented plan to maximize the recruitment and retention of direct care staff.

Facility documentation reviewed during the survey showed ongoing reliance on agency staff to meet basic staffing needs, with no evidence of initiatives or strategies to reduce agency dependency or enhance permanent staff retention.

The assessment did not inform or guide budget decisions, staffing allocations, or operational adjustments necessary to ensure compliance with licensure and certification standards. There was no documented evidence the facility used the assessment to plan for or provide the necessary resources to safely care for its resident population.

Refer F679

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(e)(2) Management


 Plan of Correction - To be completed: 04/11/2025

The facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations (including nights and weekends) and emergencies. The facility reviews and updates that assessment, as necessary, and at least annually. The facility also reviews and updates this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.
By 4/11/25, the Administrator reviewed and updated the Facility Assessment to address the following: to identify the specific activity and psychosocial needs of residents, including those with dementia and behavioral health needs; to reflect changes in the resident population and staffing levels, including those required to care for residents on the locked D1 Dementia/Memory Care Unit and the C1 Male Behavioral Health Unit; specific strategies and resources needed to care for residents with dementia, Alzheimer's disease, and behavior-related diagnoses; and the compliance and ethics program and related staff training as a component of risk or operations. Further, the Administrator included documentation indicating a dedicated or tailored activities program and corresponding budget for the D1 and C1 units; a documented plan to maximize the recruitment and retention of permanent direct care staff and strategies to reduce agency dependency.
By 4/11/25, the Temporary Manager and/or designee educated the Administrator on the need for the Facility Assessment to inform or guide budget decisions, staffing allocations, and operational adjustments necessary to ensure compliance with licensure and certification standards to ensure care of its resident population.
The Administrator will review the Facility Assessment on a monthly basis for three months to ensure it continues to inform or guide budget decisions, staffing allocations, and operational adjustments necessary to ensure compliance with licensure and certification standards to ensure care of its resident population.
The results of audits will be presented to the QA&A Committee by the Administrator. The QA&A Committee will determine the need for further auditing beyond three months.

483.10(f)(5)(i)-(iv)(6)(7) REQUIREMENT Resident/Family Group and Response: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.
§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.

§483.10(f)(6) The resident has a right to participate in family groups.

§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
Observations:

Based on a review of select facility policy, facility grievance forms, and resident and staff interviews, it was determined the facility failed to make ongoing efforts to resolve grievances and the provision of timely follow up with residents regarding the status update on the resolution process of the grievance for one out of 24 residents interviewed (Resident 27).

A review facility policy entitled "Complaints and Grievances, Filing and Investigating Resident/Family" last reviewed by the facility on January 22, 2025, indicated that upon receipt of an oral, written, or anonymous grievance submitted by a resident, the grievance official will take immediate action to prevent further potential violations of any resident rights while the alleged violation is being investigated. If the grievance committee/grievance official determines that the resident rights violation has occurred, then the violation must be corrected within 5 working days. Upon completion of the review, the grievance official will complete a written grievance decision. The grievance official will meet with the resident and inform the resident of the results of the investigation and how the resident's grievance was resolved or will be resolved within 10 working days. The facility will keep evidence of the resolution of all grievances for a period of three years from the date the grievance decision is issued.

A review of resident council notes from a meeting held on March 18, 2025, revealed a complaint from the residents in relation to call bell response times. The notes reveal the activities director would assist with submitting a grievance about the call bell response times.

An interview with the Activities Director on March 27, 2025, at 9:00 AM revealed the employee submitted a verbal grievance to the grievance official on March 19, 2025 in regard to the call bell response time.

An interview with the grievance official (Employee 11) conducted on March 28, 2025, at 10:00 AM revealed the call bell response times were added to an unresolved grievance from November 22, 2024. Further the employee stated that call bell response times continued to be an issue brought up in resident council and instead of starting a new grievance he just continues with the old one. The employee indicated call bell response time continues to be a concern and has not yet been resolved.

A review of the uploaded grievance about the call bell response time initially submitted on November 22, 2024, revealed during resident council meeting the residents' indicated concerns with staff response to call bells. Further it was indicated on that grievance on February 18, 2025, the residents continued to complain of call bell response times. The grievance remains unresolved as of the date of the survey ending on March 28, 2025.

A review of paper grievances submitted between January 2025 and March 2025 revealed Resident 27 submitted a grievance on February 25, 2025, in reference to missing clothing and blankets.

A review of the facility's grievance report submitted electronically for the grievance, revealed the resident's grievance was not filed and reviewed until March 4, 2025 six days after the resident filed his grievance about his missing items.

On March 7, 2025, faciltiy staff conducted an interview with the resident and confirmed his clothes were missing. Follow up information revealed as of March 13, 2025, the items were still being searched for and no resolution has been obtained.

An interview with Resident 27 on March 28, 2025, at 8:43 AM revealed the facility could not find his pants nor his two blankets. The resident stated he had to buy more pants out of his own money because he could not go without pants. As of the time of the interview no resolution had been provided to the resident. The resident stated he was not satisfied with how the facility was handling his missing items.

An interview on March 28, 2025, at 11:30 AM the Nursing Home Administrator confirmed the facility failed to resolve grievances as per their policy.


28 Pa Code 201.18 (e)(1) Management










 Plan of Correction - To be completed: 04/11/2025

Without admitting or denying the validity or existence of the alleged deficiencies, including but not limited to any determinations of scope or severity, Aventura at Terrace View provides the following plan of correction. This plan of correction is submitted as required by the state and federal guidelines and is not an admission or agreement with any of the cited information. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Aventura at Terrace View reserves all right to raise all possible contention and defenses in any civil or criminal claim action or proceeding.
This Plan of Correction serves as Aventura at Terrace View's credible allegation of substantial compliance as of April 11, 2025.
The facility ensures the resident has a right to organize and participate in resident groups in the facility. The facility provides a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
On 4/4/25 and on 4/9/25, the Activity Director attended follow up Resident Council meetings. On both occasions, residents in attendance voiced satisfaction with call bell response times.
By 4/11/25, the facility reimbursed Resident # 27 for missing clothing that he purchased and purchased replacement blankets. The resident expressed satisfaction with the resolution to his concern. By 4/11/25, the Social Services Director provided a supportive visit to Resident # 27. The resident had no negative psychosocial effects.
By 4/11/25, the Administrator and/or designee reviewed grievances submitted over the last 30 days to ensure resolved with timely follow up with residents regarding the status of the resolution process of the grievance.
By 4/11/25, the Temporary Manager educated the Social Services Director on the importance of making ongoing efforts to resolve grievances and on the provision of timely follow up with residents regarding the status update on the resolution process of the grievance. The facility's policy was also reviewed at this time. By 4/11/25, the Temporary Manager and/or designee educated facility staff in various departments on the same topics. The facility's policy was also reviewed at this time.
The Administrator and/or designee will review grievances submitted by individual residents/resident representatives 5 days a week for 4 weeks, then 3 days a week for 4 weeks, then weekly for 4 weeks. Additionally, the Administrator and/or designee will review grievances submitted during Resident Council meetings monthly for 3 months to ensure resolution of grievances and the provision of timely follow up with residents regarding the status updated on the resolution process of the grievance.
The results of audits will be presented to the QA&A Committee by the Administrator and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.


483.95(f)(1)(2) REQUIREMENT Compliance and Ethics Training: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.
§483.95(f) Compliance and ethics.
The operating organization for each facility must include as part of its compliance and ethics program, as set forth at §483.85-

§483.95(f)(1) An effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program.

§483.95(f)(2) Annual training if the operating organization operates five or more facilities.
Observations:
Based on record review and staff interviews, the facility failed to implement an effective compliance and ethics program, including providing required training to 6 of 6 employees reviewed (Employees 11, 12, 13, 14, 15, and 16), and failed to uphold standards of ethical conduct, as evidenced by the lack of staff training and an incident of theft involving Employee 11 and Resident 79.

Findings include:

A review of the facility's "Corporate Compliance and Ethics Plan," last updated July 2024, revealed the facility had established written policies intended to promote compliance with legal and ethical standards. The plan specified that employees must receive training on the facility's Code of Conduct, including expectations related to ethical behavior and reporting of misconduct.

According to 42 CFR the facility must develop, implement, and maintain an effective compliance and ethics program that includes:
Standards, policies, and procedures to prevent and detect criminal, civil, and administrative violations, a designated compliance officer, effective training and education for all staff, and a Code of Conduct made available to all staff.

However, during the survey the facility was unable to produce a copy of its Code of Conduct or policies related to the compliance and ethics program.

The facility assessment, last reviewed July 15, 2024, did not identify the Compliance and Ethics Program or related staff training as a component of risk or operations.

Employee files for Employees 12, 13, 14, 15, and 16, hired between February and March 2025, contained no evidence of ethics or compliance training.

The personnel file for Employee 11, who was rehired in February 2025, also lacked documentation of any such training.

Resident 79 was admitted on February 1, 2023, with a diagnosis of multiple sclerosis. An annual MDS assessment dated February 1, 2023, revealed the resident was cognitively intact (BIMS score of 15).

On March 26, 2025, Resident 79 reported to the Director of Social Services that approximately two years earlier, Employee 11, nurse aide (NA) took him to a bank to cash a $2,800 check and then offered to "hold" $2,000 of the funds for him. The resident stated that Employee 11 NA never returned the money.

A police report dated March 26, 2025, confirmed the incident had been reported. On March 27, 2025, law enforcement confirmed with a local financial institution that Resident 79 cashed a check in the amount of $3,925.77 on August 1, 2023. Employee 11 NA later admitted during police questioning that she took the money for "safekeeping" but did not return it, stating she was "scared" and made no effort to correct the issue even after the resident confronted her.

Employee 11 NA was arrested and charged with theft.

The facility failed to prevent this ethical violation through the implementation of a functioning compliance program and failed to detect or respond to unethical conduct in a timely manner. Interviews with facility leadership confirmed the compliance and ethics program was not part of orientation or ongoing training for staff, and documentation to support its implementation could not be produced.

Refer F607, F 838

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.18(b)(1)(e)(2) Management



 Plan of Correction - To be completed: 04/11/2025

F 0946 Compliance and Ethics Training
The operating organization for the facility includes as part of its compliance and ethics program an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program.
By 4/11/25, the Human Resources Director and/or designee ensured Employees # 12, # 13, # 14, # 15 and # 16 received training on the facility's compliance and ethics program. Employee # 11 no longer works at the facility.
By 4/11/25, the Administrator updated the Facility Assessment to include the compliance and ethics program and related staff training as a component of risk or operations.
By 4/11/25, the Human Resources Director and/or designee reviewed other employees to ensure they received training on the facility's compliance and ethics program and addressed identified issues accordingly.
Moving forward, the Administrator and Human Resources Director will ensure the compliance and ethics program is part of orientation and ongoing training for staff, with documentation to support its implementation.
By 4/11/25, the Temporary Manager and/or designee educated the Administrator, Human Resources Director and staff in various departments on the facility's need to implement an effective compliance and ethics program, including providing required training to employees and to uphold standards of ethical conduct.
The Human Resources Director and/or designee will review personnel files for a combination of 5 newly-hired and existing staff members 3 times a week for 4 weeks, then weekly for 4 weeks, then twice a month for one month to ensure training requirements have been met.
The results of audits will be presented to the QA&A Committee by the Human Resources Director and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.55(b)(1)-(5) REQUIREMENT Routine/Emergency Dental Srvcs in NFs: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.
§483.55 Dental Services
The facility must assist residents in obtaining routine and 24-hour emergency dental care.

§483.55(b) Nursing Facilities.
The facility-

§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(f) of this part, the following dental services to meet the needs of each resident:
(i) Routine dental services (to the extent covered under the State plan); and
(ii) Emergency dental services;

§483.55(b)(2) Must, if necessary or if requested, assist the resident-
(i) In making appointments; and
(ii) By arranging for transportation to and from the dental services locations;

§483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay;

§483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and

§483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan.
Observations:

Based on clinical record review, payor source data, and staff interview, it was determined the facility failed to provide timely and necessary dental services for one resident who is a Medicaid recipient (Resident 25) out of 24 residents reviewed.

Findings included:

Review of the clinical record indicated Resident 25 was admitted to the facility on July 2, 2014, with diagnoses to include diabetes (high blood sugars).

Review of a Quarterly Minimum Data Set assessment (MDS-standardized assessment completed at specific intervals to identify specific resident care needs) dated February 3, 2025, revealed Resident 25 was cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status, which assesses cognition, a tool to assess the resident's attention, orientation, and ability to register and recall new information, a score of 13-15 equates to being cognitively intact).

Review of a nurses note dated December 16, 2024, at 9:05 AM revealed, Resident 25 informed staff that her lower dentures had fallen out of her mouth and broken. The resident also stated she informed the dentist of the incident. Documentation indicated the social services worker was notified via voicemail, but no evidence of follow-up or action taken by the facility was found at that time.

Further nursing documentation dated December 31, 2024, at 7:41 AM revealed, Resident 25 again reported her dentures were missing, and a search by staff was unsuccessful. Social services were notified again; however, there was no documentation of timely dental referral or follow-up action between this date and the eventual dental appointment on January 27, 2025.

Nursing documentation dated January 27, 2025, at 2:35 PM 42 days after the initial report revealed the resident was seen by the dentist, who completed a full exam and noted that Resident 25 was fully edentulous and had lost her dentures. Impressions were taken for new upper and lower dentures.

Continued dental documentation on March 3, 2025, indicated the denture fabrication process was ongoing, yet by March 28, 2025, during the survey, the resident remained without dentures.

During an interview March 27, 2025, at 12:00 PM, Resident 25 stated that she had been without dentures since December 2024. She reported she coped by cutting food into smaller pieces and asked staff for assistance when needed.

During an interview on March 28, 2025, at approximately 11:00 AM the Nursing Home Administrator (NHA) was unable to produce documentation to demonstrate that timely and appropriate dental services were provided following the resident's reports on December 16. 2024 and December 31, 2024. The NHA could not explain the delay in the dental referral or the prolonged timeline for denture replacement.

28 Pa Code 211.12 (c)(d)(3)(5) Nursing services



 Plan of Correction - To be completed: 04/11/2025

The facility assists residents in obtaining routine and 24-hour emergency dental care.
On 1/27/25, Resident # 25 was seen by the facility's contracted dental service provider for a comprehensive exam. At this time, impressions for upper and lower complete dentures were taken. On 3/3/25, the resident was again seen by the dental service provider for the second step of the process to obtain dentures, i.e., the bite registration. At this time, the casts were oriented for upper and lower complete dentures. The contracted dental service provider's next availability is 4/18/25, at which time, the dentist will complete the wax try in. The resident has not required a diet change. There have been no negative clinical effects noted.
By 4/11/25, Nurses completed oral assessments on other residents. The Social Service Director communicated dental needs to the facility's contracted dental service provider accordingly.
By 4/11/25, the Temporary Manager and/or designee educated the Social Services Director, Dietitian and Nurses on the importance of providing timely and necessary dental services to residents. The facility's policy was also reviewed at this time.
The DON and/or designee will review 5 residents 3 times a week for 4 weeks, then 5 residents weekly for 4 weeks, then 5 residents twice a month for regulatory compliance with provision of timely and necessary dental services.
The results of audits will be presented to the QA&A Committee by the DON and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.35(d)(7) REQUIREMENT Nurse Aide Peform Review-12 hr/yr In-Service: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.
§483.35(d)(7) Regular in-service education.
The facility must complete a performance review of every nurse aide at least once every 12 months, and must provide regular in-service education based on the outcome of these reviews. In-service training must comply with the requirements of §483.95(g).
Observations:

Based on review of facility documentation and staff interview, it was determined the facility failed to ensure nurse aides received the required yearly 12 hours of in-service training and failed to ensure that nurse aides received an annual performance review for 5 out of 5 employees (Employee 6, 7, 8, 9, 10).

The findings include:

Review of the facility nurse aide training records revealed that Employees 6, 7, 8, 9, and 10 did not receive 12 hours of in-service training for the year 2024.

The facility failed to provide any documentation the above-mentioned employees received a performance review in the last 12 months.

An interview with the Director of Nursing and Nursing Home Administrator on March 28, 2025, at approximately 1:45 PM, confirmed the facility did not have documentation that Employee 6, 7, 8, 9, and 10 had received the required 12 hours of annual in-service training or a completed performance review for 2024.


28 Pa. Code 201.19(2)(7) Personnel policies and procedures







 Plan of Correction - To be completed: 04/11/2025

The facility completes a performance review of every nurse aide at least once every 12 months, and provides regular in-service education based on the outcome of these reviews.
By 4/11/25, the DON and/or designee completed annual performance reviews on Employees # 6, # 7, # 8, # 9 and # 10. By 4/11/25, the Human Resources Director and/or designee ensured Employees # 6, # 7, # 8, # 9 and # 10 received the required 12 hours of annual in-service training.
By 4/11/25, the Human Resources Director and/or designee reviewed training records for other nurse aides for completing the required 12 hours of in-service training for the year. By 4/11/25, the Human Resources Director and/or designee reviewed personnel files for other nurse aides to ensure annual performance reviews were completed. Identified issues were addressed accordingly.
By 4/11/25, the Temporary Manager educated the Human Resources Director and Administrator on the regulation and requirements for the nurse aides and yearly 12 hours of in-service training and that nurse aides receive an annual performance review.
The Human Resources Director and/or designee will review personnel files for 5 nurse aides 3 times a week for 4 weeks, then 5 nurse aides weekly for 4 weeks, then 5 nurse aides twice a month for one month to ensure they received 12 hours of in-service training for the year and that annual performance reviews were completed.
The results of audits will be presented to the QA&A Committee by the Human Resources Director and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.35(d)(4)-(6) REQUIREMENT Nurse Aide Registry Verification, Retraining: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.
§483.35(d)(4) Registry verification.
Before allowing an individual to serve as a nurse aide, a facility must receive registry verification that the individual has met competency evaluation requirements unless-
(i) The individual is a full-time employee in a training and competency evaluation program approved by the State; or
(ii)The individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been included in the registry. Facilities must follow up to ensure that such an individual actually becomes registered.

§483.35(d)(5) Multi-State registry verification.
Before allowing an individual to serve as a nurse aide, a facility must seek information from every State registry established under sections 1819(e)(2)(A) or 1919(e)(2)(A) of the Act that the facility believes will include information on the individual.

§483.35(d)(6) Required retraining.
If, since an individual's most recent completion of a training and competency evaluation program, there has been a continuous period of 24 consecutive months during none of which the individual provided nursing or nursing-related services for monetary compensation, the individual must complete a new training and competency evaluation program or a new competency evaluation program.
Observations:

Based on a review of facility job descriptions, personnel files, and staff interviews, it was determined the facility failed to ensure that staff renewed their nurse aide registration to allow individuals to work as a nurse aide for one of five nurse aides reviewed (Employee 5).

Findings include:

The facility's undated job description for the Nurse Aide position indicated that an active nurse aide registration was necessary to perform the duties of the role.

Review of Employee 5's personnel file showed that their Pennsylvania Nurse Aide Registration expired on February 25, 2025. The facility was unaware that Employee 5's registration was expired until it was discovered on March 18, 2025.

Despite the expired registration, Employee 5 continued to work the following day shifts from February 25, 2025, to March 18, 2025: 2/25, 2/26, 2/28, 3/1, 3/2, 3/4, 3/5, 3/6, 3/7, 3/10, 3/11, 3/12, 3/14, 3/15, 3/16, and 3/18 - totaling 127.25 hours.

Interview with the Nursing Home Administrator on March 24, 2025, at 1:30 PM confirmed the facility was unaware of the expired registration until March 18, 2025, and acknowledged that Employee 5 should not have been permitted to work during that time.

28 Pa. Code 201.29 Personnel Policies and Procedures.


 Plan of Correction - To be completed: 04/11/2025

Before allowing an individual to serve as a nurse aide, the facility receives registry verification that the individual has met competency evaluation requirements.
By 4/11/25, Employee # 5 was suspended from duty. The employee was permitted to return to work once the facility verified that the individual had met competency evaluation requirements.
By 4/11/25, the Human Resources Director and/or designee reviewed other staff to ensure receipt of registry verification that the individual has met competency evaluation requirements prior to allowing the individual to work as a nurse aide. Other nurse aides were active on the Pennsylvania Nurse Aide Registration.
By 4/11/25, the Temporary Manager educated the Human Resources Director and Administrator on requirements for nurse aide registry verification for both facility staff. The Temporary Manager also reviewed systems to track nurse aide certifications to keep and remain current.
The Human Resources Director and/or designee will review current employees weekly for 4 weeks, then monthly for two months for upcoming renewals and compliance. Additionally, newly-hired employees will be reviewed 3 times a week for 4 weeks, then weekly for 4 weeks, then two times a month for one month.
The results of audits will be presented to the QA&A Committee by the Human Resources Director and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.25(k) REQUIREMENT Pain Management: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.
§483.25(k) Pain Management.
The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Observations:

Based on review of clinical records and staff interviews it was determined that the facility failed to develop and implement individualized pain management programs, consistent with professional standards of practice, to meet the pain management needs and attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication prescribed on an as needed basis for one resident out of 24 reviewed (Resident 114).

Findings include:

According to the US Department of Health and Human Services, Interagency Task Force, Executive Summary Draft Final Report May 6, 2021, for Pain Management Best Practices the development of an effective pain treatment plan after proper evaluation to establish a diagnosis with measurable outcomes that focus on improvements including quality of life (QOL), improved functionality, and Activities of Daily Living (ADLs). Achieving excellence in acute and chronic pain care depends on the following:

An emphasis on an individualized patient-centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician.

Acute pain can be caused by a variety of different conditions such as trauma, burn, musculoskeletal injury, neural injury, as well as pain due to surgery/procedures in the perioperative period. A multi-modal approach that includes medications, nerve blocks, physical therapy and other modalities should be considered for acute pain conditions.

A multidisciplinary approach for chronic pain across various disciplines, utilizing one or more treatment modalities, is encouraged when clinically indicated to improve outcomes.

A review of Resident 114's clinical record revealed the resident was admitted to the facility on September 6, 2024, with diagnoses, which included alcoholic cirrhosis of the liver (a chronic liver disease caused by long-term excessive alcohol consumption).

A review of a physician order initially dated February 18, 2025, revealed the resident was ordered Oxycodone (narcotic pain medication) 5MG give one via G-Tube(a tube inserted into the stomach to administer nutrition and medication) every six hours as needed for increased pain.

A review of the resident's February 2025 Medication Administration Record (MAR) revealed staff administered the as needed Oxycodone 23 times for the month of February. Of the 23 doses given, 18 were administered with no non-pharmacological interventions attempted prior to giving the pain medication.

A review of the resident's March 2025 MAR revealed staff administered the as needed Oxycodone 74 times for the month of March. Of the 74 doses given, 60 were administered with no non-pharmacological interventions attempted prior to giving the pain medication.

An interview with the Nursing Home Administrator and Director of Nursing on March 28, 2025, at approximately 1:45 PM confirmed there was no evidence that non-pharmacological interventions were consistently attempted and proved ineffective prior to administration of a as needed pain medication.


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




 Plan of Correction - To be completed: 04/11/2025

The facility ensures that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.
Resident # 114's pain management regimen was reviewed. Emphasis was placed on non-pharmacological interventions that the Nurse can attempt prior to future narcotic pain medication administration.
By 4/11/25, the DON and/or designee reviewed the pain management regimen for other residents with ordered narcotic pain medications with emphasis on non-pharmacological interventions. Identified issues were addressed accordingly.
By 4/11/25, the Temporary Manager and/or designee educated Nurses on the need to attempt non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication. The facility's policy was also reviewed at this time.
The DON and/or designee will audit 5 residents who receive narcotic pain medication 3 times a week for 4 weeks, then 5 residents weekly for 4 weeks, then 5 residents twice a month to ensure Nurses attempted non-pharmacological interventions to alleviate pain prior to the administration of a narcotic pain medication.
The results of audits will be presented to the QA&A Committee by the DON and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.25(b)(2)(i)(ii) REQUIREMENT Foot Care: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.
§483.25(b)(2) Foot care.
To ensure that residents receive proper treatment and care to maintain mobility and good foot health, the facility must:
(i) Provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and
(ii) If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments.
Observations:

Based on observation, review of clinical records, and staff and resident interview, it was determined the facility failed to consistently provide timely and necessary foot care for one of 24 residents sampled (Resident 23).

Findings include:

A review of the Facility's "Foot Care" Policy revealed that residents will be provided with foot care and treatment in accordance with professional standards of practice. The policy revealed residents with foot disorders or medical conditions associated with foot complication will be referred to qualified professionals.

A review of the clinical record revealed that Resident 23 was admitted to the facility on February 15,2018, and had diagnoses, which included spastic quadriplegic cerebral palsy, (a type of cerebral palsy where arms and legs are affected by muscle stiffness making movement difficult) contractures (a condition of hardening muscles leading to deformities) of the right and left knees, and neuromuscular dysfunction of the bladder(loss of bladder control).

A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated January 17, 2025, revealed that Resident 23 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

On March 25, 2025, at 9:00 AM, an observation of Resident 23 revealed that the toenails on the left foot were excessively long, extending beyond the tips of the toes. There was evidence of dried blood beneath and along the cuticle line, and the toenails appeared yellow and encrusted with debris.

During the observation on March 25, 2025, Resident 23 stated that she had not received podiatry services while at the facility.

A review of Resident #23's clinical record showed no documented evidence indicating that podiatry services had been provided during her stay at the facility.

An interview with the Director of Nursing (DON) on March 25, 2025, at approximately 1:00 PM, confirmed Resident 23 had not received routine podiatry care as of March 25, 2025.


28 Pa. Code 211.12 (c)(d)(3)(5) Nursing Services




 Plan of Correction - To be completed: 04/11/2025

The facility ensures that residents receive proper treatment and care to maintain mobility and good foot health. The facility provides foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s); and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation and from such appointments.
During the survey, on 3/26/25, the contracted podiatrist assessed Resident # 23. At this time, the podiatrist debrided toenails.
By 4/11/25, Nurses assessed other residents and provided and/or arranged for foot care accordingly.
By 4/11/25, the Temporary Manager and/or designee educated Nurses and Nurse Aides on the need to provide residents with proper treatment and care to maintain mobility and good foot health. The facility's policy was also reviewed at this time.
The DON and/or designee will audit 5 residents 3 times a week for 4 weeks, then 5 residents weekly for 4 weeks, then 5 residents twice a month to ensure that residents receive proper treatment and care to maintain mobility and good foot health.
The results of audits will be presented to the QA&A Committee by the DON and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.24(c)(1) REQUIREMENT Activities Meet Interest/Needs Each Resident: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.
§483.24(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 review of clinical records, resident council meeting minutes, and resident and staff interviews, it was determined the facility failed to provide an ongoing program of activities designed to meet the needs, interests, and preferences of residents as expressed by seven out of seven individuals interviewed during resident interviews. (Residents 3, 23, 27, 49, 80, 81).

Findings include:

A resident group interview was held March 27, 2025, at approximately 1:00PM, 6 out of 6 residents (3, 25, 47, 49, 80, 81) present reported that many activities they enjoyed such as trips to Walmart and gardening have been removed from the activities schedule. The residents reveal there is no change in activities and that the activities are the same each week.

A review of the activity calendars for January, February, and March of 2025 revealed no change in activities each month. The activities specified on each unit revealed no variety in activities from week to week.

A review of the clinical record revealed that Resident 23 was admitted to the facility on February 15, 2018, and had diagnoses which included spastic quadriplegic cerebral palsy, (a type of cerebral palsy where arms and legs are affected by muscle stiffness making movement difficult) contractures (a condition of hardening muscles leading to deformities) of the right and left knees, and neuromuscular dysfunction of the bladder(loss of bladder control).

A review of a yearly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 2, 2025, revealed that Resident 23 is cognitively intact with a BIMS score of 15 (Brief Interview for Mental Status- a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 13-15 indicates cognition is intact).

An interview conducted with Resident #23 on March 27, 2025, at approximately 9:00 AM, revealed that her favorite leisure activity is coloring. However, she stated that she has not been given the opportunity to engage in this activity for some time.

A subsequent review of Resident #23's activity participation records showed no documentation indicating that coloring had been offered as an option. Instead, the activity log noted her participation in physical, sport-like activities, including bowling, volleyball, bean bag toss, and an exercise club.

However, a review of the resident's physical therapy evaluation, completed on January 31, 2025, indicated that Resident #23 has physical limitations that prevent her from participating in any sport-like activities. This suggests a disconnect between the activities recorded and the resident's actual physical capabilities.

During an interview with the Activity Director on March 28, 2025, at 9:00 AM, it was clarified that Resident #23 did not actively participate in the sports activities listed in the records, but rather observed while other residents took part in activities such as bowling, volleyball, and bean bag toss.

The Activity Director further explained that the facility currently has no allocated budget for resident activities. Staff members are reportedly purchasing activity-related prizes using their own personal funds, without reimbursement. In response to these limitations, the Activity Director stated that she organizes fundraiser's to support the activity department and is doing her best to develop engaging programs within the constraints of the available resources.

Observations conducted on the D Unit throughout the survey period, from March 25 through March 28, 2025, revealed groups of residents sitting in front of a television that was playing an old western movie. During these observations, residents were neither offered nor encouraged to participate in any structured activities.

In a follow-up interview with the Nursing Home Administrator (NHA) on March 28, 2025, at 1:00 PM, the NHA confirmed that the facility does not currently maintain a budget for resident activities. The Administrator acknowledged the facility's obligation to provide an ongoing program of activities tailored to meet the individual needs, interests, and preferences of each resident.

28 Pa. Code 201.29 (a) Resident rights.


 Plan of Correction - To be completed: 04/11/2025

The facility provides, 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.
By 4/11/25, the Activity Director updated activity preferences for Residents # 3, # 23, # 27, # 49, # 8.
By 4/11/25, the Activity Director updated medical record documentation for Resident # 23 to indicate that activity programming modifications are made to sport-like activities so that the resident may continue to be an active participant.
By 4/11/25, the Activity Director educated activity staff on the importance of offering Resident # 23 the opportunity to engage in coloring.
By 4/11/25, the Activity Director updated activity preferences and activity careplans for other residents.
By 4/11/25, based on resident activity preferences, the Activity Director updated the activity calendar to include a greater variety of activities from week to week.
By 4/11/2025 the regional director of operations approved a budget of $500 per month for the activities department.
By 4/11/25, the Temporary Manager and/or designee educated activity staff on the importance of providing an ongoing program of activities designed to meet the needs, interests, and preferences of residents. The facility's policy was also reviewed at this time.
The Activity Director and/or designee will audit 5 residents 3 times a week for 4 weeks, then 5 residents weekly for 4 weeks, then 5 residents twice a month to ensure the provision of activities designed to meet the needs, interests, and preferences of residents.
The results of audits will be presented to the QA&A Committee by the Activity Director and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents: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.
§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;
Observations:

Based on clinical record reviews, resident interviews, and observations, the facility failed to ensure that dependent residents received the necessary services to maintain personal hygiene for 2 of 24 residents reviewed for activities of daily living (ADLs) (Residents #23 and #96).


Findings include:

A review of the facility's Activities of Daily Living" Policy last reviewed January 22, 2025, revealed it is the facility's responsibility to provide the necessary services to maintain good grooming/personal hygiene to residents who are unable to carry out activities of daily living. The policy then goes on to state the facility is responsible to provide bathing, dressing, grooming, and oral care to residents who are unable to carry out these activities themselves.

A review of the clinical record revealed that Resident 23 was admitted to the facility on February 15, 2018, and had diagnoses, which included spastic quadriplegic cerebral palsy, (a type of cerebral palsy where arms and legs are affected by muscle stiffness making movement difficult) contractures (a condition of hardening muscles leading to deformities) of the right and left knees, and neuromuscular dysfunction of the bladder(loss of bladder control).

A review of the resident's Annual Minimum Data Set assessment (MDS- a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 2, 2025, revealed the resident was unable to shower/bathe self, further defining the resident was unable to wash, rinse, and dry self. The MDS revealed the resident is completely dependent on staff for transfers in and out of the tub or shower.

The resident's care plan, revised on February 12, 2025, indicated a preference for bed baths due to her mobility limitations. Her scheduled bed baths were to occur every Monday and Thursday during the 3PM-11PM shift.

A review of the resident's shower Documentation indicated the last recorded bed bath was provided on March 24, 2025. Observations on March 25, 2025, at 10:00AM showed the resident had dirt under her nails, unkempt, greasy hair with visible dandruff, and food stains on her hospital gown. The resident could not recall the last time her hair was washed and stated, "they just wash me up in bed sometimes, but they do not wash my hair."

A second observation conducted on March 25, 2025, at 1:00PM, revealed the resident to still have food particles on her hospital gown that were previously observed at 10:00AM, the resident's condition prevents the resident from removing the food particles herself.

A clinical record review revealed documentation the resident was given a bed bath again on March 27, 2025, at 10:00AM.

An interview with the resident conducted March 27, 2025, at 11:30AM revealed a statement from the resident stating that she was not given a bed bath, the resident's hair was still unwashed and greasy.

An observation conducted March 28, 2025, at 11:00AM revealed the resident to have food particles left on her hospital gown from the morning meal.

An interview with the resident conducted March 28, 2025, at 11:00AM confirmed the staff frequently leaves food particles on her chest area after assisting her with eating, the resident stated she has not had her hair washed and that she would like to have her hair washed each time she receives a bed bath.

There was no documented evidence in the resident's clinical record or care plan of any resident refusals or reasons for not washing the resident's hair as scheduled and as requested.

Clinical record review revealed Resident 96 was admitted to the facility on August 4, 2023, with diagnosis to include dementia (a condition that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment) and anxiety (a feeling of fear, dread, and uneasiness).

A quarterly Minimum Data Set assessment dated February 6, 2025, revealed he was moderately, cognitively impaired with a BIMS score of 8 (brief interview for mental status, a tool to assess the resident's attention, orientation and ability to register and recall new information, a score of 8-12, indicating moderately, cognitive impairment) and required staff assistance with activities of daily living (ADL).

A review of the resident's care plan initiated: March 22, 2024, for potential for skin breakdown related to, decreased mobility, revealed interventions to include, skin checks to be completed bi-weekly with showers, shower days scheduled Mondays and Thursdays 3PM to 11PM shift. The care plan also included interventions for refusals, including re-education and reattempting care, as well as physician and social work notification.

Shower documentation for March 2025 for Resident 96, showed only two recorded bed baths on March 20 and 24, 2025. There was no documentation of additional bathing or required skin assessments. Observation on March 26, 2025, at 12:00 PM, in the presence of the resident's sister, revealed the resident's feet were covered in white sloughing (shedding) skin, with thick, mycotic (fungal) toenails and debris between the toes. His fingernails were jagged, long, and dirty.

Interview with the Director of Nursing and Nursing Home Administrator on March 28, 2025, at approximately 12:00 PM confirmed the facility failed to provide adequate services for personal hygiene to meet the residents' needs and preferences.

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



 Plan of Correction - To be completed: 04/11/2025

The facility ensures a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
On 3/31/25, the Nurse Aide assisted Resident # 23 with bathing. The resident's hair was washed and her nails were cleaned. On 4/9/25, the Social Services Director provided a supportive visit to the resident. The resident had no negative clinical or psychosocial effects.
During the survey, on 3/26/25, the podiatrist debrided the resident 23 and 96's toenails. On 3/31/25, the Nurse Aide assisted Resident # 96 with bathing. The resident's feet were cleaned. Fingernails were trimmed and cleaned. On 4/10/25, the Social Services Director provided a supportive visit to the resident. The resident had no negative clinical or psychosocial effects.
By 3/29/25, the DON and/or designee observed other residents to ensure no food particles remained on clothing after meals. By 4/11/25, the DON and/or designee interviewed other residents to obtain bathing preferences. Bathing schedules were reviewed and updated accordingly. By 4/11/25, the DON and/or designee observed other residents' fingernails and cleaned and/or trimmed accordingly.
By 4/11/25, the Temporary Manager and/or designee educated Nurses and Nurse Aides on the need to assist residents with bathing according to their preferences. This includes bathing, dressing, grooming, and nail care. Staff were also educated on the importance of keeping residents' clothing free of food particles after meals. The facility's policy was also reviewed at this time.
The Nurse Supervisor and/or designee will audit 5 residents 3 times a week for 4 weeks, then 5 residents weekly for 4 weeks, then 5 residents twice a month to ensure Nurse Aides assist residents with bathing as indicated, to ensure fingernails are kept clean and trimmed and to ensure clothing is free of food particles after meals.
The results of audits will be presented to the QA&A Committee by the DON and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:
Based on a review of the facility's abuse prohibition policy and employee personnel files and staff interviews, it was determined the facility failed to implement abuse prohibition procedures to fully screen five out of five sampled employees (Employees 12, 13, 1, 15 and 16) to ensure they were eligible for employment in a long term care nursing facility.

Findings include:

A review of the facility's policy titled Resident Abuse (reviewed January 2025) indicated that all potential employees are to be screened prior to hire. This includes contacting references and obtaining pertinent information from former and current employers to assess for any past history of abuse, neglect, or professional misconduct.

However, a review of personnel files revealed the following:

Employee #12 (housekeeper), hired February 3, 2025, had previous employment listed in the application. There was no evidence that the facility attempted to contact prior employers.

Employee #13 (nurse aide), hired February 21, 2025, lacked documentation of any reference checks or employment verification.

Employee #1 (LPN), hired February 15, 2025, lacked evidence of attempts to contact former employers or verify prior employment.

Employee #15 (RN), hired March 7, 2025, had no documentation indicating prior work references were contacted.

Employee #16 (van driver), hired March 19, 2025, had no evidence of reference checks or employment history verification.

In an interview conducted on March 27, 2025, at 11:15 a.m., the Human Resources Director confirmed the above findings. She acknowledged she had not contacted previous employers for the five employees and stated, "I'm new to this job and didn't know that I had to call prior work references as part of the employment process."

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

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 201.19 (1) Personnel records






 Plan of Correction - To be completed: 04/11/2025

The facility develops and implements written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; establishes policies and procedures to investigate any such allegations, and includes training as required; establishes coordination with the QAPI program; ensures reporting of crimes occurring in federally-funded long-term care facilities. The policies and procedures include but are not limited to the following elements: posting a conspicuous notice of employee rights, prohibiting and preventing retaliation.
By 4/11/25, the Human Resources Director and/or designee attempted and/or completed screens on Employees 12, 13, 1, 15 and 16. Specifically, the facility attempted to contact prior employers for Employee # 12. The facility attempted to complete reference checks and employment verification for Employee # 13. The facility attempted to contact former employers and verify prior employment for Employee # 1. The facility attempted to contact prior work references for Employee # 15. The facility attempted to complete reference checks and employment history verification for Employee # 16.
By 4/11/25, the Human Resources Director and/or designee reviewed other employee's personnel files to ensure they were appropriately screened prior to hire and addressed accordingly.
By 4/11/25, the Regional Director of Operations educated the Human Resources Director and Administrator on the need to implement abuse prohibition procedures to fully screen employees that they are eligible for employment in a long-term care nursing facility.
The Administrator and/or designee will audit newly-hired employees 3 times a week for 4 weeks, then weekly for 4 weeks, then twice a month for one month to ensure that abuse prohibition procedures are implemented to fully screen employees to ensure they are eligible for employment in a long-term care nursing facility.
The results of audits will be presented to the QA&A Committee by the Human Resources Director and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.10(e)(1), 483.12(a)(2) REQUIREMENT Right to be Free from Physical Restraints: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.
§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints.
Observations:

Based on observations, review of select facility policy, clinical record review, and staff interview, it was determined the facility failed to ensure that residents were free from physical restraints for one of 24 residents reviewed (Resident 74).

Findings include:

Review of facility policy entitled "Right to be Free from Restraints" last reviewed January 22, 2025, indicated the purpose is for each resident to attain and maintain his/her highest practical well-being in an environment that prohibits the use of physical restraints for discipline or convenience, prohibits the use of physical restraints to unnecessarily inhibit a resident's freedom of movement or activity, and limits physical restraint use to circumstances in which the resident has medical symptoms that may warrant the use of restraints. Further it is indicated when a physical restraint must be used, the facility will use the least restrictive restraint for the least amount of time and provide ongoing re-evaluation of the need for the physical restraint.

A review of the clinical record revealed Resident 74 was admitted to the facility on April 25, 2022, with diagnoses which included end stage renal disease (a condition where the kidneys can no longer adequately filter waste and excess fluid from the blood), bipolar disorder (a mental health condition characterized by extreme mood swings), and obsessive compulsive disorder (a disorder marked by uncontrollable and recurring thoughts and/or repetitive and excessive behaviors).

A review of physician's orders initially dated March 15, 2024, revealed an order for protective mittens (a type of physical restraint) on at bedtime and during times of agitation to prevent the resident from pulling at her dialysis catheter (a soft, flexible tube inserted into a large vein, typically in the neck or chest, that allows blood to be accessed for dialysis treatments). The mittens were to be removed every 2 hours for a skin assessment.

An observation of the resident on March 25, 2025, at 9:45 AM revealed the resident was calm and no agitation was noted. The resident was in her Broda chair ( tilt-in-space positioning chair) sleeping by the nursing station. Further observation revealed the resident's physical restraints (mittens) were in place despite the resident being calm and resting.

An observation of the resident on March 25, 2025, at 1:20 PM revealed again the resident was calm and no agitation observed. The resident was in her Broda chair sleeping by the nursing station. Further observation revealed the resident's physical restraints (mittens) were in place despite the resident being calm and resting.

An observation of the resident on March 26, 2025, at 12:45 PM revealed the resident was sitting calmly in the dining room being fed by staff. The resident did not appear to be agitated. Further observation revealed the resident's physical restraints were in place despite the resident being calm and resting.

An observation of the resident on March 27, 2025, at approximately 10:00 AM revealed the resident was calm and no agitation was noted. The resident was once again in her Broda chair sleeping by the nursing station. Further observation revealed the resident's physical restraints were in place despite the resident being calm and resting.

An interview with the Nursing Home Administrator and Director of Nursing on March 28, 2025, at approximately 1:45 PM confirmed the facility failed to ensure that Residents 74 was free from physical restraints and the use of the mittens was limited to the least amount of time necessary.

28 Pa. Code 201.29 (a) Resident Rights

28 Pa. Code 211.8(c.1) Use of Restraints

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




 Plan of Correction - To be completed: 04/11/2025

The facility ensures the resident is free from any physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. When the use of restraints is indicated, the facility ensures the last restrictive alternative is used for the least amount of time and ongoing re-evaluation of the need for restraints is documented.
On 4/9/25, the IDT met with Resident # 74's responsible party. At this time, the responsible party expressed desire for the continued use of hand mittens. The physician was updated on the responsible party's wishes and the resident's status. The physician was agreeable to the continued use of protective hand mittens on during times of agitation and at HS, with removal to check skin integrity.
By 4/11/25, the Director of Rehabilitation reviewed other residents with physician-ordered devices. No device was determined to restrict movement. Devices were determined to treat the resident's medical symptoms and to assist the resident with functioning.
By 4/11/25, the Temporary Manager and/or designee educated Nurses on the facility's policy for physical restraints and federal regulation for physical restraints that the resident is free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
The Director of Nursing (DON) or designee audit residents with orders for restraints 3 times a week for 4 weeks, then weekly for 4 weeks, then twice a month for one month to determine adherence to physician orders.
The results of audits will be presented to the QA&A Committee by the DON and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.12 REQUIREMENT Free from Misappropriation/Exploitation: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.
§483.12
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.
Observations:
Based on interview, record review, and review of facility policy and investigative reports, the facility failed to ensure that one of 24 sampled residents (Resident 79) was free from misappropriation of property, monetary, by a facility staff member.

Findings include:

A review of the facility's Abuse policy, last revised January 2025, revealed it is the policy of the facility that acts of physical, verbal, psychological and financial abuse directed against residents are absolutely prohibited. Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, involuntary seclusion, mistreatment, neglect exploitation and misappropriation of property. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful, (temporary or permanent) use of a resident's belongings or money without the resident's consent.

Clinical record review revealed Resident 79 was admitted to the facility on February 1, 2023, with diagnoses of multiple sclerosis (a progress neurological disorder).

An annual Minimum Data Set assessment dated February 1, 2023 (Minimum Data Set - a federally mandated standardized assessment conducted at specific intervals to plan resident care) revealed the resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact).

A review of facility documentation dated March 26, 2025, at 3:35 PM, Resident 79 reported to the Director of Social Services that approximately two years prior, a facility nurse aide (Employee 11) transported him to a bank to cash a check totaling $2,800.00 (from his employment prior to admission). He stated that Employee 11, whom he knew prior to his admission, advised him not to retain such a large sum of money at the facility and offered to hold $2,000.00 for him. Resident 79 stated that the money was never returned.

The Social Worker, Nursing Home Administrator (NHA), and Director of Nursing (DON) met with the resident to discuss the concern. When asked why he had not reported the incident sooner, the resident stated that he did not think to mention it until now and was planning to be discharged soon and needed the money. Employee 11 was suspended from duty on March 27, 2025, and the matter was referred to local law enforcement.

A written statement dated March 27, 2025 (no time documented), provided by Employee 11, indicated that she denied ever having seen, handled, or taken possession of Resident 79's money. She stated that after a period of about seven months without contact, she began receiving text messages from the resident referencing "money under my mattress." Employee 11 stated that other staff members told her the resident had made similar allegations to them. She reported informing the resident that she did not have his money and that making such accusations was inappropriate. Employee 11 stated that she notified nursing supervisors and the scheduler that she was uncomfortable with the accusations and requested not to work on the resident's unit. She denied taking any money from the resident.

A written statement dated March 26, 2025, provided by the Social Services Director (SSD), indicated that Resident 79 approached him on that date to report the alleged misappropriation. The resident stated that Employee 11 took him to the bank, assisted him in cashing a check from previous employment, and advised him that it was unsafe to keep a large amount of money at the facility. He reported that the aide offered to hold $2,000.00 for him but never returned the funds. The resident stated that Employee 11 now denies the incident ever occurred.

In another statement from March 26, 2025 (no time documented), Resident 79 reiterated that Employee 11 had taken him to a check cashing facility where he cashed a check for $2,800.00. He stated that she offered to hold $2,000.00 for him "for a rainy day" but now denies any knowledge of the transaction.

A review of a local police incident report dated March 26, 2025, at 5:24 PM revealed that the DON contacted the police at approximately 5:20 PM to report the incident. According to the report, Employee 11 had taken Resident 79 to a bank to cash a $2,800.00 check and advised him to give her $2,000.00 for safekeeping, stating it was not safe to keep that amount of money at the facility. The aide reportedly told the resident she would keep it "under her mattress."

The DON informed the police that Employee 11 had resigned from the facility in February 2024 and was re-hired in February 2025. She further stated that the resident had recently confronted Employee 11, who denied any knowledge of the money, after which the resident began reporting to other staff that she had stolen money from him.

On March 27, 2025, the police officer conducted interviews at the facility. Resident 79 confirmed the allegation that Employee 11 had taken $2,000.00 after accompanying him to a check cashing facility. The officer contacted the local business, which confirmed that Resident 79 cashed a check on August 1, 2023, in the amount of $3,925.77, issued from an investment company.

Employee 11 was interviewed at the police station. She acknowledged taking Resident 79 from the facility on multiple occasions, including to cash the referenced check, but stated she did not seek formal approval from the facility. She indicated the incident occurred in the summer of 2023. After the resident cashed the check, she expressed concern about him having so much money and offered to hold $2,000.00 for him. The resident agreed, and she accepted the money. She reported that several weeks later, the resident began sending text messages accusing her of stealing the money and requesting its return. Employee 11 admitted that she did not return the money because she was "scared." She further stated that after facility staff became aware of the situation, the resident stopped asking for the money, and she did not attempt to return it.

Employee 11 was taken into custody and charged with theft.

Employee 11 was suspended on March 27, 2025, and later terminated. During interviews on March 28, 2025, the DON and Nursing Home Administrator (NHA) confirmed the incident constituted misappropriation of the resident's property.

28 Pa. Code 201.29 (a)(b) Resident rights

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


 Plan of Correction - To be completed: 04/11/2025

The facility ensures the resident is free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to threat the resident's medical symptoms.
On 3/26/25, the facility initiated an investigation in response to Resident # 79's allegation of misappropriation that allegedly occurred approximately two years prior. Employee # 11 was suspended from duty and subsequently terminated. The matter was referred to local law enforcement. Resident # 79 no longer resides at the facility.
By 4/11/25, the Social Services Director and/or designee interviewed other residents regarding potential misappropriation of personal property. None expressed concern.
By 4/11/25, the Temporary Manager and/or designee educated staff in various departments on the resident's right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
The Social Services Director and/or designee will interview 5 residents 3 times a week for 4 weeks, then 5 residents weekly for 4 weeks, then 5 residents twice a month for one month to ensure none have concerns related to potential misappropriation of resident property. If concerns are identified, the facility's Abuse Coordinator will be immediately notified and an investigation initiated accordingly.
The results of audits will be presented to the QA&A Committee by the Administrator and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.10(j)(1)-(4) REQUIREMENT Grievances: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.
§483.10(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on observations, a review of a select facility policy, and resident and staff interviews, it was determined the facility failed to provide and/or make information regarding the facility's grievance policy and the residents' rights to file a grievance readily available in prominent locations on the nursing units for two of five units as reported by five of six residents interviewed. (Residents 25, 47, 49, 80, 81)

Findings include:

A review of select facility policy entitled "Complaints and Grievances, Filing and Investigating Resident/Family" last reviewed January 22, 2025, indicated a copy of the facility's grievance forms and grievance procedures are posted on the B1, C1, C2,and D unit across from the nurse's station on the bulletin boards. On the B2 unit the grievance forms and grievance procedures are located in the meditation room.

During a group interview conducted on March 26, 2025, at approximately 11:00 AM, six alert and oriented residents participated. Of those six residents, five (Residents 25, 47, 49, 80, and 81) reported that they did not know how to file a grievance without assistance from the Resident Council President.

An observation of the B2 nursing unit on March 26, 2025, at approximately 1:20 PM revealed there were no posted grievance procedures or instructions on how to file a grievance in the meditation room.

An observation of the C1 nursing unit on March 26, 2025, at approximately 1:45 PM revealed there were no posted grievance procedures or instructions on how to file a grievance in the area across from the nursing station.

During an interview conducted on March 28, 2025, at approximately 1:45 PM, the Nursing Home Administrator and Director of Nursing confirmed the facility had failed to post and provide residents with the procedures for filing a grievance.

28 Pa. Code 201.29 (a)(c.1) Resident rights.




 Plan of Correction - To be completed: 04/11/2025

The facility ensures the resident has the right to and the facility makes prompt efforts to resolve grievances the resident may have. The facility ensures information on how to file a grievance or complaint is made available to the resident.
On 4/8/25, the Social Services Director made information regarding the facility's grievance policy and the resident's right to file a grievance readily available in prominent locations on the B2 and C1 nursing units.
On 4/9/25, the Activity Director attended the Resident Council meeting to discuss the location of the facility's grievance policy and to review the process of filing a grievance with residents in attendance at the meeting.
Department heads explained to all alert and oriented residents on their normal room round assignments the locations of grievance forms and the process to file a grievance.
By 4/11/25, the Temporary Manager and/or designee educated staff in various departments on the facility's Grievance policy, as well as on the importance of providing information regarding the facility's grievance policy and the resident's right to file a grievance readily available in prominent locations on the nursing units.
The Social Services Director and/or designee will audit the five nursing units 3 times a week for 4 weeks, weekly for 4 weeks, then twice a month for one month to ensure information regarding the facility's grievance policy and the resident's right to file a grievance readily available in prominent locations on the nursing units.
The results of audits will be presented to the QA&A Committee by the Social Services Director and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment: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.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

The facility must provide-
§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.
(i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.
(ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft.

§483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

§483.10(i)(3) Clean bed and bath linens that are in good condition;

§483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv);

§483.10(i)(5) Adequate and comfortable lighting levels in all areas;

§483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and

§483.10(i)(7) For the maintenance of comfortable sound levels.
Observations:

Based on a review of select facility policy, observations, and staff interview, it was determined the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment and resident care equipment for one resident out of 24 sampled (Resident 114).


Findings include:

A review of a facility policy entitled "Tube Feeding Management" last reviewed January 22, 2025, indicated staff should maintain and clean the feeding pump and equipment.

Review of Resident 114's clinical record revealed the resident was admitted to the facility on September 6, 2024, with diagnoses which included dysphagia (difficulty swallowing) and unspecified severe protein calorie malnutrition (a condition characterized by a severe deficiency of both protein and calories resulting in significant wasting of muscle and fat, and potentially leading to life-threatening complications).

Resident 114 required a PEG tube (Percutaneous endoscopic gastrostomy an endoscopic medical procedure in which a tube is passed into the patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) for enteral feeding (enteral nutrition generally refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements).

An observation on March 25, 2025, at 9:45 AM revealed dried tube feed solution was noted on the pump, pole, stand, wall, and floor.

An observation on March 26, 2025, at 10:06 AM revealed a large amount of dried tube feed noted on the floor . The dried tube feeding solution was still noted on the pump, pole, stand, and wall.

An observation on March 27, 2025, at 10:05 AM revealed dried tube feed solution was noted on the pump, pole, stand, wall, and floor.

Interview with the Nursing Home Administrator and Director of Nursing on March 28, 2025, at approximately 1:45 PM, confirmed resident equipment and the environment was to be maintained in a clean and sanitary manner.


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

28 Pa. Code 201.14(a) Responsibility of Licensee

28 Pa. Code 201.14(b)(1) Management




 Plan of Correction - To be completed: 04/11/2025

The facility ensures the resident has a right to a safe, clean, comfortable and homelike environment, including, but not limited to receiving treatment and supports for daily living safely.
On 3/27/25, the Housekeeper cleaned Resident # 114's room to ensure no dried tube feed solution on the pump, pole, stand, wall and floor.
By 3/27/25, the Director of Housekeeping and/or designee inspected the rooms of other residents receiving tube feeding to ensure no spills on the pump, pole, stand, wall and/or floor and addressed accordingly.
By 4/11/25, the Temporary Manager and/or designee educated housekeeping staff on the need to provide housekeeping services necessary to maintain a clean and sanitary environment and resident care equipment. Specifically, staff was educated on the importance of cleaning any dried tube feed solution on the pump, pole, stand, wall and/or floor that may have inadvertently spilled. The facility's policy was also reviewed at this time.
The Director of Housekeeping and/or designee will randomly inspect the rooms of 3 residents receiving tube feeding 3 times a week for 4 weeks, then weekly for 4 weeks, then twice a month for one month to ensure the absence of tube feed solution on the pump, pole, stand, wall and/or floor that may have inadvertently spilled.
The results of audits will be presented to the QA&A Committee by the Director of Housekeeping and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.10(f)(10)(iv)(v) REQUIREMENT Notice and Conveyance of Personal Funds: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.
§483.10(f)(10)(iv) Notice of certain balances.
The facility must notify each resident that receives Medicaid benefits-
(A) When the amount in the resident's account reaches $200 less than the SSI resource limit for one person, specified in section 1611(a)(3)(B) of the Act; and
(B) That, if the amount in the account, in addition to the value of the resident's other nonexempt resources, reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI.

§483.10(f)(10)(v) Conveyance upon discharge, eviction, or death.
Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility must convey within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.
Observations:

Based on interview, and record review of clinical records and resident trust account records, it was determined the facility failed to ensure residents' personal funds held by the facility were refunded within 30 days of discharge or death for forty-two of 42 residents sampled (Residents CR1, CR2, CR3, CR4, CR5, CR6, CR7, CR8, CR9, CR10, CR11, CR12, CR13, CR14, CR15, CR16, CR17, CR18, CR19, CR20, CR21, CR22, CR23, CR24, CR25, CR26, CR27, CR28, CR29, CR30, CR31, CR32, CR33, CR34, CR35, CR36, CR37, CR38, CR39, CR40, CR41 and CR42 ).

Findings include:

Review of clinical and financial records revealed that the following residents had remaining balances in their resident trust accounts at the time of discharge, and that those funds had not been refunded within 30 days.

Clinical record review revealed that Resident CR1 was admitted to the facility on January 19, 2024, and discharged on August 6, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $1642.00 remaining in his resident trust account (personal bank account facilitated by the facility) at the time of his discharge from the facility.

Clinical record review revealed that Resident CR2 was admitted to the facility on March 3, 2017, and discharged on January 3, 2025.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $894.83 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR3 was admitted to the facility on October 10, 2018, and discharged on January 7, 2022.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $83.98 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR4 was admitted to the facility on January 28, 2024, and discharged on August 15, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $824.55 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR5 was admitted to the facility on June 11, 2021, and discharged on July 28, 2022.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $1978.40 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR6 was admitted to the facility on November 25, 2021, and discharged on July 5, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $2487.72 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR7 was admitted to the facility on December 30, 2022, and discharged on June 10, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $18.87 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR8 was admitted to the facility on April 5, 2024, and discharged on August 15, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $898.00 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR9 was admitted to the facility on August 5, 2020, and discharged on August 21, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $1203.80 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR10 was admitted to the facility on April 21, 2017, and discharged on October 14, 2022.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $9.00 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR11 was admitted to the facility on January 4, 2023, and discharged on March 20, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $2616.00 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR12 was admitted to the facility on February 9, 2023, and discharged on March 29, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $3933.37 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR13 was admitted to the facility on September 25, 2023, and discharged on February 13, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $809.00 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR14 was admitted to the facility on May 8, 2017, and discharged on December 6, 2022.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $950.39 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR15 was admitted to the facility on November 16, 2023, and discharged on June 29, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $10,949.30 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR16 was admitted to the facility on January 18, 2017, and discharged on February 14, 2022.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $1440.42 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR17 was admitted to the facility on February 7, 2023, and discharged on April 12, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $936.10 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR18 was admitted to the facility on November 30, 2023, and discharged on April 5, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $2229.80 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR19 was admitted to the facility on April 4, 2024, and discharged on June 2, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $349.40 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR20 was admitted to the facility on April 22, 2022, and discharged on November 20, 2022.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $1418.19 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR21 was admitted to the facility on February 22, 2022, and discharged on January 6, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $2971.45 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR22 was admitted to the facility on October 7, 2023, and discharged on January 12, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $1749.00 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR23 was admitted to the facility on July 15, 2019, and discharged on May 11, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $2238.69 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR24 was admitted to the facility on April 6, 2020, and discharged on August 11, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $1143.17 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR25 was admitted to the facility on September 27, 2024, and discharged on October 29, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $2175.00 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR26 was admitted to the facility on January 3, 2023, and discharged on February 16, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $1764.32 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR27 was admitted to the facility on July 23, 2014, and discharged on September 17, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $524.05 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR28 was admitted to the facility on August 13, 2015, and discharged on December 1, 2022.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $1359.00 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR29 was admitted to the facility on January 13, 2023, and discharged on April 1, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $2510.00 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR30 was admitted to the facility on May 12, 2021, and discharged on August 19, 2021.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $792.63 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR31 was admitted to the facility on April 4, 2024, and discharged on May 3, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $3523.01 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR32 was admitted to the facility on March 31, 2023, and discharged on December 9, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $1496.20 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR33 was admitted to the facility on July 3, 2020, and discharged on January 4, 2022.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $2789.71 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR34 was admitted to the facility on January 11, 2023, and discharged on October 1, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $2032.40 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR35 was admitted to the facility on May 6, 2020, and discharged on January 18, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $127.35 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR36 was admitted to the facility on August 5, 2022, and discharged on January 20, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $5632.79 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR37 was admitted to the facility on January 2, 2020, and discharged on October 24, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $398.10 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR38 was admitted to the facility on August 26, 2022, and discharged on December 4, 2022.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $20.25 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR39 was admitted to the facility on January 28, 2020, and discharged on August 14, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $511.26 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR40 was admitted to the facility on January 17, 2020, and discharged on May 26, 2022.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $621.15 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR41 was admitted to the facility on March 4, 2022, and discharged on August 7, 2024.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $2368.60 remaining in his resident trust account at the time of his discharge from the facility.

Clinical record review revealed that Resident CR42 was admitted to the facility on April 23, 2021, and discharged on August 27, 2023.

A review of a document provided by the Nursing Home Administrator on March 26, 2025; the resident had $291.28 remaining in his resident trust account at the time of his discharge from the facility.

Review of a document provided by the Nursing Home Administrator (NHA) on March 26, 2025, revealed that each of these residents had remaining balances in their resident trust accounts (facility-managed personal funds) at the time of discharge. Individual resident account balances ranged from $9.00 to $10,949.30, and the total amount not refunded to the residents, or their representatives was $72,312.54.

During an interview on March 26, 2025, at 11:00 AM, the Temporary Manager confirmed the above-listed residents had not received refunds of their trust account balances within 30 days of discharge.

In a follow-up interview on March 26. 2025 at 11:15 AM, the Nursing Home Administrator verified the facility had not issued required refunds within 30 days of death or discharge to any of the 42 residents or their estate representatives.


28 Pa. Code: 201.18 (b)(2)(e)(1) Management.

28 Pa. Code 201.29(a) Resident rights






 Plan of Correction - To be completed: 04/11/2025

Upon the discharge, eviction, or death of a resident with a personal fund deposited with the facility, the facility conveys within 30 days the resident's funds, and a final accounting of those funds, to the resident, or in the case of death, the individual or probate jurisdiction administering the resident's estate, in accordance with State law.
By 4/11/25, the Business Office Manager and/or designee conveyed funds and provided a final accounting of those funds accordingly to the following residents and/or the individual or probate jurisdiction administering the residents' estate: CR1, CR2, CR3, CR4, CR5, CR6, CR7, CR8, CR9, CR10, CR11, CR12, CR13, CR14, CR15, CR16, CR17, CR18, CR19, CR20, CR21, CR22, CR23, CR24, CR25, CR26, CR27, CR28, CR29, CR30, CR31, CR32, CR33, CR34, CR35, CR36, CR37, CR38, CR39, CR40, CR41 and CR42.
By 4/11/25, the Business Office Manager and/or designee reviewed other residents with a personal fund deposited with the facility to ensure proper conveyance of funds and a final accounting of those funds over the last 3 months.
By 4/11/25, the Temporary Manager and/or designee educated the Business Office Manager on the need to ensure residents' personal funds held by the facility are refunded within 30 days of discharge or death. The federal regulation and the facility's policy were also reviewed at this time.
The Administrator and/or designee will audit weekly for 4 weeks, then monthly for 4 months to ensure proper conveyance of funds and a final accounting of those funds for those residents discharged from the facility.
The results of audits will be presented to the QA&A Committee by the Business Office Manager and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.10(f)(10)(vi) REQUIREMENT Surety Bond-Security of Personal Funds: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.
§483.10(f)(10)(vi) Assurance of financial security.
The facility must purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.
Observations:

Based on review of the residents' personal funds account and facility surety bond, and staff interview, it was determined the facility failed to ensure the surety bond coverage met or exceeded the balance for the total residents' personal funds account for four months (October 2024, November 2024, December 2024 and January 2025) and failed to assure that the obligee (the bond's beneficiary) of the surety bond was in favor of the residents of the facility.

Findings include:

Review of the facility's surety bond dated January 21, 2024, indicated the amount of surety was $150,000 on this date. The obligee was noted as The Pennsylvania Department of Health.

A review of the balance of the resident fund accounts deposited with the facility from October 1, 2024 through January 16, 2025 the total amount in the resident account exceeded $150,000 on the following dates:

October 1, 2024--162,970.68
October 2, 2024--160,05403
October 3, 2024--207,236.26
October 7, 2024--167,168.26
October 8, 2024--161,681.02
October 9, 2024--170,357.23
October 10, 2024-175,054.13
October 11, 2024-162,750.93
October 15, 2024-162,869.86
October 16, 2024-168,440.35
October 21, 2024-162,548.35
October 23, 2024-164,082.35
October 24, 2024-160,136.12
October 28, 2024-160,097.12
October 30, 2024-162,893.36
October 31, 2024-162,727.56

November 1, 2024-164,365.56
November 4, 2024-164,890.53
November 5, 2024-164,846.21
November 6, 2024-164,419.40
November 7, 2024-164,424.40
November 12, 2024-179,760.62
November 13, 2024-172,731.50
November 14, 2024-164,771,40
November 18, 2024-164,981.40
November 20, 2024-170,812.40
November 21, 2024-165,062.40
November 27, 2024-173,189.34
November 29, 2024-172,429.74

December 2, 2024-169,043.23
December 3, 2024-207,226.57
December 4, 2024-166,041.78
December 10, 2024-166,464.78
December 11, 2024-174,474.88
December 16, 2024-166,164.78
December 17, 2024-166,101.78
December 18, 2024-171,949.78
December 20, 2024-166,209.78
December 24, 2024-167,818.78
December 26, 2024-168,941.02
December 27, 2024-166,557.78
December 30, 2024-157,565.56
December 31, 2024-163,759.01

January 2, 2025-163,976.24
January 3, 2025-199,988.23
January 6, 2025-162,516.03
January 7, 2025-165,100.14
January 8, 2025-173,301.04
January 10, 2025-165,302.43
January 13, 2025-163,094.03
January 14, 2025-162,781.03
January 15, 2025-168,841.03
January 16, 2025-163,311.03


Interview with the business office manager on March 25, 2025, at approximately 10 a.m., confirmed the facility administrative staff failed to acquire a surety bond with coverage that met or exceeded the balance in the residents' personal funds account for that time period.

A review of the facility surety bond also confirmed the obligee of the bond, who would collect in case of loss, was The Pennsylvania Department of Health. Upon interview with the nursing home administrator on March 25, 2025, it was confirmed the facility failed to assure the residents of the facility would be compensated in case of loss.

28 Pa. Code 201.18 (b)(2)Management

28 Pa Code 201.14(a) Responsibility of licensee.


 Plan of Correction - To be completed: 04/11/2025

The facility ensures the purchase of a surety bond, or otherwise provides assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility.
On 3/26/25, the facility acquired a surety bond that meets or exceeds the balance for the total residents' personal funds account.
By 4/11/25, the Temporary Manager educated the Administrator and Business Office Manager on the regulation for the surety bond coverage to meet or exceed the balance for the total residents' personal funds account.
The Administrator and/or designee will review residents with personal funds deposited with the facility weekly for 3 months to ensure the surety bond meets or exceeds the balance for the total residents' personal funds account. Thereafter the business office manager will review the resident funds account during the weekly account reconciliation ensure the bond amount remains sufficient.
The results of audits will be presented to the QA&A Committee by the Administrator and/or designee. The QA&A

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

Based on observations, select facility policy, a review of clinical records, and staff interviews, it was determined the facility failed to provide supplemental oxygen administration and care consistent with professional standards of practice for two of 24 residents reviewed (Resident 114 and 93).

Findings include:

A review of facility policy entitled "Oxygen Management" last reviewed January 22, 2025, indicated it is the policy of the facility to provide safe oxygen management. The facility will obtain physician orders for oxygen therapy to include prescribed flow rates, when to change the humidifier bottle, and when to change the tubing or mask. Further it is indicated that the maintenance and cleaning of oxygen equipment are consistent with federal, state, and local laws and regulations.

Review of Resident 114's clinical record revealed the resident was admitted to the facility on September 6, 2024, with diagnoses, which included acute respiratory failure (a condition in which your blood doesn't have enough oxygen) with hypoxia (low levels of oxygen in your body tissues).

An observation on March 25, 2025, at 9:45 AM and March 26, 2025, at 10:06 AM revealed the resident was receiving oxygen at 4.5 liters per minute.

A review of the resident's physician's orders revealed no orders for the resident to receive oxygen on a continuous or as needed basis.

A review of Resident 93's clinical record revealed admission to the facility on May 1, 2024, with diagnoses, which included radiculopathy (a condition where the nerve roots become compressed or irritated. This compression or irritation can lead to pain, numbness, tingling, weakness), hypotension (low blood pressure), and peripheral vascular disease (a group of conditions that affect the blood vessels outside the heart and brain, primarily in the legs).

A review of physician's orders initially dated March 20, 2025, revealed the resident was to receive oxygen at 2 liters per minute per nasal cannula every eight hours as needed for shortness of breath or an oxygen level below 94% initially dated March 8, 2023.

Further review of Resident 93's physician's orders revealed no orders as to when or how often the tubing should be changed per the facility policy.

An observation of Resident 93 on March 26, 2025, at 8:50 AM revealed the resident was lying in bed receiving 2 liters of oxygen. The oxygen tubing was not dated to indicate when the tubing was put into use to alert staff as to when the oxygen tubing should be changed.

An observation of Resident 93 on March 27, 2025, at 10:14 AM revealed the resident was lying in bed. The resident's oxygen tubing was observed lying on the floor.

A subsequent observation of the resident on March 27, 2025, at 11:00 AM revealed the resident now had the oxygen tubing that was seen on the floor during the prior observation present and was receiving 2 liters of oxygen. The tubing remained undated at that time.

An interview with Nursing Home Administrator and Director of Nursing on March 28, 2025, at approximately 1:45PM revealed oxygen tubing should be changed weekly and confirmed the facility failed to provide supplemental oxygen administration and care consistent with professional standards of practice.


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



 Plan of Correction - To be completed: 04/11/2025

The facility ensures 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, and the residents' goals and preferences.
On 4/1/25, an order was obtained from the physician for oxygen administration for Resident # 114.
On 4/8/25, the Nurse obtained an order for Resident # 93 to change oxygen tubing. The Nurse obtained new oxygen tubing and dated it accordingly.
By 4/11/25, the DON and/or designee observed other residents who receive oxygen to ensure the tubing was properly positioned. By 4/11/25, the DON and/or designee reviewed other residents who receive oxygen to ensure orders are in place to support supplemental oxygen administration. By 4/11/25, the DON and/or designee reviewed other residents who receive oxygen to ensure orders for oxygen tubing changes are in place. By 4/11/25, other residents were observed to ensure oxygen tubing was dated. Identified issues were addressed accordingly.
By 4/11/25, the Temporary Manager and/or designee educated Nurses on the need to provide supplemental oxygen administration and care consistent with professional standards of practice. Specifically, Nurses were educated on the need to ensure orders are in place to support supplemental oxygen administration, oxygen tubing is properly placed, orders are in place for oxygen tubing changes, and oxygen tubing is dated to indicate when the oxygen tubing should be changed. The facility's policy was also reviewed at this time.
The DON and/or designee will audit 5 residents who receive supplemental oxygen 3 times a week for 4 weeks, then 5 residents weekly for 4 weeks, then 5 residents twice a month to ensure orders are in place to support supplemental oxygen administration, oxygen tubing is properly placed, orders are in place for oxygen tubing changes, and oxygen tubing is dated to indicate when the oxygen tubing should be changed.
The results of audits will be presented to the QA&A Committee by the DON and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.60(d)(1)(2) REQUIREMENT Nutritive Value/Appear, Palatable/Prefer Temp: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.
§483.60(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, staff and resident interviews, and test tray temperature results, the facility failed to ensure that food was served at palatable and appetizing temperatures for one (1) of three (3) nursing units observed (First Floor D Unit).

Findings include:

According to the federal regulation 483.60(i)-(2) Food safety requirements - the definition of "Danger Zone", found under the Definitions section, is food temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow rapid growth of pathogenic microorganisms that can cause foodborne illness.

On March 25, 2025, at 12:00 PM, observation of the lunch tray line revealed the planned lunch meal included: baked chicken patty, roasted potatoes, corn, milk, lemon drink, ice cream, and coffee.

A test tray was requested for the First Floor-D Unit. The tray included a regular diet chicken patty, roasted potatoes, corn, lemon drink, and coffee.

Review of meal service revealed the trays were delivered in an enclosed cart to the First Floor D Unit at 11:25 AM. However, staff were still assisting residents to the dining area, and tray distribution did not begin until 11:50 AM. The last tray was served at 12:15 PM, approximately 45 minutes after the trays arrived on the unit.

At 12:15 PM, a test tray revealed the following food temperatures:
Chicken patty: 104.5potatoes: 107.5106.7items were observed to be cool and not palatable, falling within the "Danger Zone" as defined by regulation, and failing to meet the requirement for appetizing temperature.

In addition, the ice cream on the test tray measured 35and was melted, rendering it not palatable at the time it was served.

An interview with the Nursing Home Administrator on March 25, 2025, at 3:00 PM, confirmed the facility did not consistently serve food at acceptable and appetizing temperatures.

28 Pa Code 201.18(1) Management


 Plan of Correction - To be completed: 04/11/2025

The facility ensures each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance; and food and drink that is palatable, attractive, and at a safe and appetizing temperature.
By 4/11/25, the Dietitian reviewed medical record documentation for residents residing on the D unit. None had documented concerns of gastric distress.
By 4/11/25, the Temporary Manager and/or designee educated Nurses and Nurse Aides on the need for the facility to provide residents with food and drink that is palatable, attractive, and at a safe and appetizing temperature. Specifically, Nurses and Aides were educated on the need to distribute meal trays in a timely manner so that acceptable food temperatures are maintained. The facility's policy was also reviewed at this time.
The Dietary Manager and/or designee will conduct one test tray per meal on varying units 5 times a week for 4 weeks, then one test tray per week for 4 weeks, then one test tray per meal twice a month for one month to ensure food and drink that is palatable and at a safe and appetizing temperature. The dietary Manager will also temp food in the kitchen before it is served to ensure proper temperatures.
The results of audits will be presented to the QA&A Committee by the Dietary Manager and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.45(c)(3)(e)(1)-(5) REQUIREMENT Free from Unnec Psychotropic Meds/PRN Use: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.
§483.45(e) Psychotropic Drugs.
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic

Based on a comprehensive assessment of a resident, the facility must ensure that---

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record review and staff interviews, it was determined the facility failed to ensure that medication regimens were managed and monitored to promote or maintain the residents' highest practicable physical, mental, and psychosocial well-being, as evidenced by the lack of resident-specific rationale to support the continued use of psychoactive medications for two residents out of 5 residents sampled (Resident 11 and 30).

Findings include:

A review of clinical records revealed Resident 30 was admitted to the facility on November 2, 2016, with diagnoses to included dementia with mood disturbances (problems with reasoning, planning, judgment, memory, and other thought processes caused by brain damage from impaired blood flow to your brain).

A review of a quarterly Minimum Data Set assessment (MDS-a federally mandated standardized assessment process conducted periodically to plan resident care) dated February 12, 2025, revealed that Resident 30 is severely cognitively impaired with no BIMS score noted in the form(Brief Interview for Mental Status-a tool within the Cognitive Section of the MDS that is used to assess the resident's attention, orientation, and ability to register and recall new information; a score of 0 -7 indicates severely impaired cognition).

A physician's order dated May 13, 2024, revealed, Xanax 0.25 mg (an antianxiety medication) by mouth at bedtime for anxiety.

A physician's order dated April 24, 2024, revealed, Zoloft 100 mg by mouth every day, later increased to 150 mg daily on November 21, 2024, by the physician.

A review of documentation by the Certified Registered Nurse Practitioner (CRNP) dated March 21, 2025, failed to provide resident-specific rationale for the continued use of these psychoactive medications. At the time of the survey ending March 28, 2025, no documentation was found that supported the ongoing clinical justification for both the antianxiety and antidepressant medications.

A review of clinical records revealed Resident 11 was admitted to the facility on July 6, 2018, with diagnoses to included dementia with mood disturbances.

A review of an annual Minimum Data Set assessment dated February 21, 2025, revealed that Resident 11 is severely cognitively impaired with no BIMS score recorded.

A physician's order dated October 25, 2024, revealed, Prozac 10 mg (antidepressant) by mouth every day for depression.

The CRNP documentation dated March 21, 2025, again failed to demonstrate a clinically relevant, individualized rationale supporting the continued use of the psychoactive medication. No further documentation was available at the time of the survey ending March 28, 2025, to support the appropriateness of the medication regimen.

During an interview with the Director of Nursing on March 28, 2025, at approximately 12:00 PM, the DON confirmed that documentation lacked resident-specific justification for the continued use of the psychoactive medications for Residents 11 and 30.

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

28 Pa. Code 211.9(a) (1) Pharmacy Services

28 Pa. Code 211.2(3) Medical Director





 Plan of Correction - To be completed: 04/11/2025

Based on a comprehensive assessment of a resident, the facility ensures residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record.
Resident # 30's medication regimen was reviewed. The Nurse Practitioner provided documented rationale for the continued use of ordered antianxiety and antidepressant medications.
Resident # 11's medication regimen was reviewed. The Nurse Practitioner provided documented rationale for the continued use of ordered antidepressant medications.
By 4/11/25, the DON and/or designee reviewed other residents with ordered psychotropic medications to ensure documented rationale to support the continued use of the medications.
By 4/11/25, the Temporary Manager and/or designee educated Nurses on the importance of managing and monitoring medication regimens to promote or maintain the residents' highest practicable physical, mental, and psychosocial well-being. Specifically, Nurses were educated on the importance of the physician and/or nurse practitioner providing resident-specific rationale for the continued used of psychoactive medications. The facility's policy was also reviewed at this time. By 4/11/25, the DON and/or designee educated Physicians and Nurse Practitioners on the same topics, as well as on the facility's policy.
Based on consultant pharmacist reports, the DON and/or designee will review residents once a month for 3 months to ensure the Physician and/or Nurse Practitioner documented rationale for the continued use of psychotropic medications.
The results of audits will be presented to the QA&A Committee by the DON and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
§483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

§483.10(g)(11) The facility must--
(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility.
(ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and
(iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.
(iv) The facility shall not make available identifying information about complainants or residents.
Observations:

Based on observation and resident interview, it was determined the facility failed to ensure the Department of Health's most recent survey results were readily accessible to residents and visitors on two units out of 5 units observed.

Findings Include:

During a resident council interview on March 26,2025, at 10:00 AM, 6 alert and oriented residents (Residents 49, 25, 3, 80, 47 and 81) in attendance indicated they did not know where the facility posted the Department of Health survey results.

During an observation on March 27, 2025, at 10:00AM on the C2 Unit, the survey results binder was located behind the nurses' station where residents were prohibited to enter.

An observation on March 27, 2025, on the B2 Unit Nursing Station revealed the survey results were not posted or accessible to residents and visitors. Residents and visitors were not able to access the survey results without asking staff for assistance.

During an interview on March 28, 2025, at approximately 11:00 AM, the Nursing Home Administrator (NHA) confirmed it is the facility's responsibility to ensure the most recent Department of Health survey results were posted in a manner that was readily accessible to residents, family members, and legal representatives of residents.


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









 Plan of Correction - To be completed: 04/11/2025

The facility ensures the resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility posts in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. The facility ensures reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available upon request. The facility posts notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. The facility ensures identifying information about complainants or residents is not made available.
By 4/11/25, the Administrator ensured the Department of Health's most recent survey results were readily accessible to residents and visitors on C2 and B2 nursing units.
On 4/9/25, the Activity Director attended the Resident Council meeting and reviewed the location of the Department of Health survey results. Department heads explained to all alert and oriented residents on their normal room assignments the location of the survey results binders.
By 4/11/25, the Temporary Manager and/or designee educated the Administrator and staff in various departments on the regulations for posting both Department of Health and Life Safety surveys for 3 years. The survey results are posted in a manner that is readily accessible to residents, family members, and legal representatives of residents.
The Administrator and/or designee will audit weekly for 4 weeks, then monthly for two months for placement and that surveys remain posted in a manner that is readily accessible to residents, family members, and legal representatives of residents.
The results of audits will be presented to the QA&A Committee by the Administrator and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is 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(k).
Observations:

Based on review of clinical records, facility initiated transfer notices and staff interview it was determined the facility failed to provide sufficiently detailed written notices of facility initiated transfers to the resident and the residents' representative for one out of 24 residents reviewed (Residents 114).

Findings include:

Regulatory requirements indicate that before a facility transfers or discharges a resident, the facility must, 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 the resident or responsible party understand.

A review of the clinical record of Resident 114 revealed the resident was transferred to the hospital on February 27, 2025, and returned to the facility on February 28, 2025.

A review of the resident's "Notice of Transfer/Discharge" letter revealed the resident was transferred to the hospital due to epistaxis (a nose bleed). The written notice lacked the reason for the transfer in a language and manner the resident and resident representative would understand.

During an interview with the Nursing Home Administrator and Director of Nursing on March 28, 2025, at approximately 1:45 PM, confirmed the facility was unable to provide documented evidence the facility provided written notices of discharge to the resident and resident representative in a language they would understand .



28 Pa. Code 201.14(a) Responsibility of Licensee





 Plan of Correction - To be completed: 04/11/2025

Before the facility transfers or discharges a resident, the facility notifies 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.
By 4/11/25, the Admissions Director reviewed transfers and discharges for the last 30 days to ensure the resident and resident's representative(s) were notified of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand.
By 4/11/25, the Temporary Manager or designee will educate the Admissions Director, Social Services, and licensed nursing staff on the need to provide sufficiently detailed written notice of facility initiated transfer to the resident and resident's representative.
The Admissions Director and/or designee will audit resident transfer/discharges 3 times a week for 4 weeks, then weekly for 4 weeks, then twice a month to ensure the facility notifies 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 results of audits will be presented to the QA&A Committee by the Admissions Director and/or designee. The QA&A Committee will determine the need for further auditing beyond three months.


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