Pennsylvania Department of Health
 GREENERY CENTER FOR REHAB AND NURSING
Patient Care Inspection Results

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GREENERY CENTER FOR REHAB AND NURSING
Inspection Results For:

There are  263 surveys for this facility. Please select a date to view the survey results.

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GREENERY CENTER FOR REHAB AND NURSING - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on May 9, 2025, it was determined that Greenery Center for Rehabilitation and Nursing was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(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 review of facility policy, observations, and staff interview, it was determined that the facility failed maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen).

Findings include:

Review of the facility policy "Dietary Food Handling", dated 8/9/24, indicated the guidelines for the safe handling, preparation and storage of perishable food and proper environmental cleaning. Thermometers must be placed in hot and cold storage areas and temperatures must be maintained at the the following settings for the items indicated below:
Cold food- 45 degrees or below
Frozen food- zero degrees or below
Hot food- 140 degrees or above
All potentially hazardous food must be kept below 45 degrees or above 140 degrees.
Food must be stored off the floor
Food handlers must be free from communicable diseases, lesions on hands or other exposed body parts.
Clean uniforms must be worn daily. Hairnets or caps must be worn in food service areas. Facial hair must be covered.

During an observation in the Main Kitchen on 5/5/25, from 8:43 a.m., through 9:23 a.m., the following was observed:

- ice build-up was identified on all shelves of the ice cream freezer causing ice build upon ice cream containers.

- the deep freezer and refrigerator freezer units had boxes of food touching the ceilings.

-condensation and ice build up under the fan and on the pipes of the fan in the refrigerator/freezer causing ice formation on multiple boxes of frozen goods and additionally on top of containers of multiple food items stored underneath.

-Human Resources Employee E10 entered the kitchen area with no hair restraint.

-temperature logs for the dish machine, freezers, and refrigerators were incomplete for April 2025 and May 2025 and documentation of temperatures of previous months were not included in the information provided.

During an interview on 5/5/25, at 9:23 a.m., Dietary Manager Employee E9 confirmed the above findings.

During a second observation of trayline on 5/5/25, at 12:40 p.m., Dietary Aide Employee E11 was serving food from the steam table without facial hair covered.

During an interview on 5/5/25, at 1:00 p.m., the Nursing Home Administrator confirmed that the facility failed to maintain sanitary conditions to prevent the potential for cross-contamination or foodborne illness in the main kitchen (Main Kitchen).


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

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

28 Pa. Code: 211.6(c) Dietary services.





 Plan of Correction - To be completed: 06/25/2025

NHA and Dietary manager disposed of food that was potentially contaminated, removed boxes from the floor and touching the ceiling. The shelves, fan and pipes that had ice build up were defrosted. Beard nets were purchased immediately and education was provided to staff regarding updating the temperature logs.
Dietary staff have been educated on the facility Dietary/Food handling policy which includes guidelines for food temp logs, hair/beard nets, food storage and kitchen cleanliness.
Dietary Manager/Designee will audit daily 5x a week for 2 weeks and then 2x a week for 4 weeks that dietary staff are adhering to the dietary/food handling policy as it pertains to hair/beard nets, recording food temps and kitchen cleanliness regarding ice build up.
Findings will be submitted to QAPI for review and further action if needed.

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 review of facility documents, observations, and resident and staff interviews it was determined that the facility failed to provide necessary services to maintain grooming and personal hygiene for seven of twelve residents (Residents R500, R503, R504, R505, R507, R16 and R86).

Findings include:

Review of the facility policy "Personal Care Need" dated 8/9/24, indicated the facility strives to promote a health environment and prevent infection by meeting the personal care needs of the residents. The facility also provides the needed support when resident performs their activity of daily living (ADLs). Personal care and support include but is not limited to the following: ambulating, assistance with meals, bath/shower, catheter care, denture care, grooming/dressing, mouth care, nail care, peri care, repositioning, restraint releases, shampoo, shave, splints, toileting and transfers.

During a resident group interview on 5/6/25, at 10:30 a.m., five of eight residents in attendance stated, they consistently miss getting their shower schedule and have to make multiple requests to attempt to be re-scheduled. The residents in attendance expressed frustration regarding not getting showers as scheduled or with their attempts in getting showers re-scheduled. The residents reported the staff state "we are short staff today, there is no hot water, we are busy helping residents who can't help themselves first, or the power is out" (this has occurred recently with the storms locally). Residents state you can't get rescheduled. Residents stated they have reported this at their resident council meeting.

Review of the 11/4/24 and 4/2/25 resident council meeting minutes, under the topic /concern section, reveals resident complaints regarding not getting showers as scheduled. 1/7/25 and 3/3/25 minutes residents complain about not getting help with care (no council meeting in February due to Covid).

Review of the clinical record indicated Resident R16 was admitted to the facility on 9/17/11.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/19/25, included diagnoses of gait abnormalities, history of a stroke, aphasia (partial loss of the ability to articulate needs) and hemiplegia (complete paralysis on one side of the body) right side. Review of Section C: Cognitive Patterns revealed Resident R16 to have a BIMS score of 15, which indicated the resident was cognitively intact. Review of Section GG: 0130 Functional Abilities, indicated Resident R16 required substantial/maximal assistance with a shower.

Review of the Care plan dated 7/24/24 indicates Resident R16 prefers showers as scheduled and PRN (as needed).

Review of Resident R16 shower record for 4/8/25, through 5/6/25, revealed Resident R16 was documented as having received one shower, with no refusals documented.

During an interview on 5/7/25, at 11:36 a.m. Resident R16 stated she does not receive enough showers, and further stated that she has rarely refused a shower.

Review of the clinical record indicated Resident R86 was admitted to the facility on 12/13/24.

Review of the MDS dated 3/20/25, included diagnoses of heart failure and pulmonary edema. Review of Section C revealed Resident R86 to have a BIMS score of 11 which indicated mild cognitive impairment.

During an interview on 5/6/25, at 10:30 a.m., Resident R86 stated that if you don't take your shower on the day you are scheduled you are not offered one again until your next shower date and sometimes not at all.

Review of Resident R86's documentation of showers from 3/19/25, through 5/6/25, identified eight of 14 opportunities for showers that had not been provided.

During an interview on 5/7/25 at 2:00 p.m. the Nursing Home Administration (NHA) confirmed the facility failed to provide necessary services to maintain grooming and personal hygiene .

28 PA. Code:201.18(b)(2) Management.

28 PA. Code:201.29(a) Resident's Rights.







 Plan of Correction - To be completed: 06/25/2025

Residents R16, and R86 care needs have been addressed regarding showers.
The DON/Designee completed a shower preference audit to confirm that resident preferences were accommodated.
DON/Designee will review shower assignments with staff.
DON/Designee will educate staff on facility Personal Care Policy and how to report showers that are not completed as scheduled and to document.
DON/Designee will audit resident showers 3X a week for 4 weeks to ensure showers adhere to schedule and/or that documentation of why they were not completed has occurred, and then 1X weekly for 3 weeks. NHA/designee will monitor feedback monthly through resident council.
Findings will be submitted to QAPI for review and further action if needed.

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

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

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

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

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

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

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

Based on observations and interview, the facility failed to ensure medical supplies were properly disposed of and not reused for one of four residents with an ostomy (hole made in abdominal wall to allow urine/feces to pass through); failed to ensure the consistent implementation of infection control procedures during medication administration for one of three observations; and failed to store medications in a safe and sanitary manner for two of three medication carts reviewed (North cart #2, and North cart #1)

Findings:

Review of facility policy "Infection Prevention and Control Program" reviewed 8/4/24, indicated the infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.

Review of facility policy "Infection Control" reviewed 8/4/24, indicated all personnel will be trained on our infection control policies and procedures upon hire and periodically thereafter.

Review of facility policy "Ostomy Care (Colostomy, Jejunostomy, Ileostomy, Ileo conduit)" (ostomy - surgical opening that allows waste to pass out of the body; colostomy - opening between abdomen and the colon, or large intestines; jejunostomy - opening between abdomen and middle small intestines; ileostomy.- opening between abdomen and lower small intestines.) reviewed 8/9/24, indicated the procedure for ostomy care was to maintain cleanliness and skin integrity, to prevent odors, and to prevent infections, and included the following steps:
#1 - Verify physician's orders and nursing care plan. #2 - Gather equipment, don appropriate PPE (personal protective equipment) gown, gloves, mask, face shield. #6 - Remove old appliance carefully. Warm water may loosen adhesive or a small amount of adhesive remover, if indicated. #7 - Discard old appliance in the plastic bag. Retain clamp as appropriate. #16 - Measure the stoma. #20 - Remove paper backing and position the appliance over the stoma. #23 - Dispose of used supplies in plastic bag and transport to the soiled utility room. #27 - Notify physician of any changes in stoma color or skin around stoma. #28 - Document: Date/time, color and integrity of stoma and surrounding skin, color and amount of output from stoma, and resident's tolerance to procedure. #29 - Standard precautions will be observed throughout the procedure.

Review of the facility provided grievances indicated on 4/11/25 Resident R300 reported that a Licensed Practical Nurse (LPN) Employee E1 on evening shift removed his colostomy bag and threw it in the garbage. When she was unable to get another bag to fit, she removed the soiled bag from the garbage, cleaned it with bleach, and reapplied it. Resident R300 reported that although this action caused him no pain or discomfort, it did make him feel nervous.

Resident R300 was unavailable for interview.

During an observation on 5/6/25, at 9:20 a.m. with the Nursing Home Administrator, multiple sizes of ostomy supplies were noted to be in stock and available for resident use.

During a telephone interview on 5/6/25, at 10:00 a.m. LPN Employee E1 stated Resident R300's call bell was ringing for approximately one hour, and she had to go find the resident's nurse aide to go empty the colostomy bag. She stated the bag was full and almost 'bursting'. LPN Employee E1 went into the residents room to change the colostomy bag but stated she was unable to find one that fit correctly, so she removed the soiled bag from the garbage, rinsed it out with mouthwash, wiped the outside with bleach and reapplied the soiled bag to the stoma. LPN Employee E1 stated she learned to use mouthwash when she was a nurse aide to help with the smell and anti-bacterial properties. She stated that she did not ask for assistance or help when she noticed the clean ostomy bag did not fit. She denied looking for the correct supplies in the supply room.

During an observation on 5/7/25, at 10:00 a.m. LPN Employee E3 returned to her medication cart with a glucometer for blood sugar monitoring. She placed the glucometer on top of her cart, then proceeded to place the glucometer in the medication cart drawer without cleansing it first.

During an interview at that time, LPN Employee E3 stated that she always cleans the glucometer before using it. This was not observed prior to her using the glucometer, and confirmed the insulin pens were unbagged.

During an observation on 5/7/25, at 10:10 a.m., North cart #2 contained five of seven unbagged insulin pens in a compartment together, posing a risk for cross-contamination.

During an interview on 5/7/25, at 10:10 a.m. Licensed Practical Nurse (LPN) Employee E3 confirmed the insulin pens were unbagged..

During an observation on 5/7/25, at 10:16 a.m. North cart #1 contained six of nine unbagged insulin pens in a compartment together, posing a risk for cross-contamination.

During an interview on 5/7/25, at 10:16 a.m. LPN Employee E2 confirmed the insulin pens were not in bags and stated she was off for three days and came back to the medication cart not being the same as she left it.

During an interview on 5/7/25 at 10:50 a.m. the Director of Nursing confirmed the facility failed to prevent the risk of cross-contamination, and failed to ensure proper infection control practices were followed.

28 Pa code 201.14(a)Responsibility of Licensee.

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




 Plan of Correction - To be completed: 06/25/2025

The Team #1 #2 North medication cart unbagged insulin medications were bagged to provide a safe and sanitary manner preventing the risk of cross-contamination by storing insulin pens
unbagged.
DON/Designee will educate licensed staff on Glucometer cleaning and where to locate ostomy supplies.
Medication carts throughout the facility were audited for any unbagged insulin medications providing for the safe and sanitary manner in which insulin pens are kept.
DON/Designee will educate licensed nursing staff on the safe and sanitary practices for storing insulin pens in separate bags.
The DON or designee will audit 3 out of the 5 facility medication carts weekly for safe and sanitary practices for storing insulin pens. The DON/Designee will observe staff using glucometers 2X a week for 4 weeks to ensure that they are following the facility policy on glucometer cleaning. Findings will be submitted to QAPI for review and further action if needed.

483.25(f) REQUIREMENT Colostomy, Urostomy, or Ileostomy 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(f) Colostomy, urostomy,, or ileostomy care.
The facility must ensure that residents who require colostomy, urostomy, or ileostomy services, receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:
Based on review of facility policy, clinical records, observations and and staff interviews, it was determined that the facility failed to provide ostomy (surgically-made opening that allows waste to pass out of the body) care and services consistent with professional standards of practice for three of four residents (Resident R73, R144, and R300).

Findings include:

Review of facility policy "Ostomy Care (Colostomy, Jejunostomy, Ileostomy, Ileo conduit)" (ostomy - surgical opening that allows waste to pass out of the body; colostomy - opening between abdomen and the colon, or large intestines; jejunostomy - opening between abdomen and middle small intestines; ileostomy.- opening between abdomen and lower small intestines.) reviewed 8/9/24, indicated the procedure for ostomy care was to maintain cleanliness and skin integrity, to prevent odors, and to prevent infections, and included the following steps:
#1 - Verify physician's orders and nursing care plan. #2 - Gather equipment, don appropriate PPE (personal protective equipment) gown, gloves, mask, face shield. #6 - Remove old appliance carefully. Warm water may loosen adhesive or a small amount of adhesive remover, if indicated. #7 - Discard old appliance in the plastic bag. Retain clamp as appropriate. #16 - Measure the stoma. #20 - Remove paper backing and position the appliance over the stoma. #23 - Dispose of used supplies in plastic bag and transport to the soiled utility room. #27 - Notify physician of any changes in stoma color or skin around stoma. #28 - Document: Date/time, color and integrity of stoma and surrounding skin, color and amount of output from stoma, and resident's tolerance to procedure. #29 - Standard precautions will be observed throughout the procedure.

Review of the clinical record indicated Resident R73 was re-admitted to the facility on 5/1/25, with diagnoses that included bladder cancer, right lower leg fracture, and history of falling.

Review of a progress note dated 4/12/25, at 9:55 a.m. indicated Resident R73 had a urostomy (opening created in abdominal wall to allow urine to bypass the bladder and exit the body).

Review of the physician's orders failed to indicate urostomy care, the frequency of care needed, or supplies needed.

Review of the care plan failed to indicate interventions for urostomy care, including specific type and size of appliance to be utilized..

During an interview on 5/6/25, at 9:07 a.m. Resident R73 stated that she cared for her own ostomy while she was at home, but now that she's in the facility, her daughter has been caring for it. She stated she brought her own supplies from home because that is what they are familiar with. She stated that staff at the facility provided care once, but the dressing did not stay on as long as when her daughter did it, so she prefers her daughter to provide the ostomy care.

Review of the clinical record indicated Resident R144 was admitted to the facility on 5/2/25.

Review of Resident R144's admission clinical record documentation dated 5/2/25, stated "Ileostomy present, Ileostomy stoma WNL (within normal limits). Ileostomy stoma care provided".

Review of Resident R144's physician order dated 5/6/25, did not include care for the Ileostomy.

Review of plan of care initiated on 5/2/25, did not include Ileostomy care, including specific type and size of appliance to be utilized.

Review of the clinical record indicated Resident R300 was admitted to the facility 4/9/25, with diagnoses that included colostomy status, diverticulitis with perforation (small pouches in the walls of the colon become infected and rupture), and chronic pain.

Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 4/15/25, indicated the diagnoses are current.

Review of the physician's orders dated 4/9/25, indicated the following:
- Change colostomy bag as needed for every three days.
-Colostomy care every shift and as needed for maintenance.
-Empty and clean colostomy bag as needed.
-Empty and clean colostomy bag every shift for maintenance.

Review of the care plan initiated 4/11/25, indicated the following interventions in place:
-Colostomy care every shift and as needed.
-Empty ostomy bag every shift and as needed.
-Encourage adequate fluid intake to promote bowel movements.
-Follow up with gastroenterologist (stomach/intestine specialist) as needed/ordered.
-Monitor and record BM's (bowel movements), noting consistency and amount.
-Observe abdomen for distention, pain, bowel sounds, constipation, or no BM.
-Observe for indicators of ostomy malfunction.
-Observe for signs and symptoms of irritation, infection, and trauma around stoma,
-Ostomy care/management per orders.
- Resident has a colostomy and requires help with ostomy care and management.

Review of the physician orders and care plan fail to indicate the specific type and size of appliance needed for colostomy care and maintenance for Resident R300.

During an interview on 5/8/25, at 10:00 a.m. LPN Employee E2 stated the nurses are responsible for resident's ostomy care. She would gather the supplies needed to change the ostomy. She stated the resident's usually have the supplies needed in their rooms.

During an interview on 5/8/25, at 10:10 a.m. LPN Employee E3 stated she would gather supplies prior to changing the ostomy appliance. She stated there are supplies in the resident's room and also in central supply.

During an interview on 5/8/25, at 10:18 a.m. LPN Employee E4 stated she gathers supplies before entering the resident's room to change an ostomy. She stated that she has changed Resident R144's ostomy several times since he was admitted.

During an interview on 5/8/25, at 10:00 a.m., the Nursing Home Administrator confirmed that the facility failed to provide colostomy care and services consistent with professional standards of practice for three of four residents.

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

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

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


 Plan of Correction - To be completed: 06/25/2025

Resident R144 and R73 have been assessed to ensure that there were no issues or concerns with their urostomy.Resident R144 and R73, and current residents have complete orders for care and appliances with inclusive care plans of all needs.
Resident R300 has been discharged from the facility.
DON/Designee has educated current nursing/aides on ostomy care policy and where to locate supplies and will continue to educate new hires as they start and prior to providing care to residents.
DON/Designee has completed an audit on current residents with Colostomy, Urostomy, or Illeostomy to verify that there are no concerns or issues with care.
DON/Designee will audit residents with colostomy's 3X a week for 4 weeks and then weekly for 4 weeks to ensure that orders are complete and care plan is inclusive of residents needs.
Findings will be submitted to QAPI for review and further action if needed

483.24(c)(2)(i)(ii)(A)-(D) REQUIREMENT Qualifications of Activity Professional: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)(2) The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who-
(i) Is licensed or registered, if applicable, by the State in which practicing; and
(ii) Is:
(A) Eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body on or after October 1, 1990; or
(B) Has 2 years of experience in a social or recreational program within the last 5 years, one of which was full-time in a therapeutic activities program; or
(C) Is a qualified occupational therapist or occupational therapy assistant; or
(D) Has completed a training course approved by the State.
Observations:

Based on staff interviews and review of facility provided documentation, it was determined the facility failed to provide a qualified professional to direct the activities program as required from (4/9/24 through 5/9/25).

Findings include:

The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional.

Review of the Activities Director job description indicated, "The primary purpose of the job position is to plan, organize, implement, evaluate and direct the activity programs in accordance with current federal, state and local standards governing the facility and as directed by the Administrator, to ensure that the emotional, recreational, and social needs of the residents are met and maintained on an individual basis."

Review of the Activity Director's Employee E6 background reveals a Bachelor of Arts, Parks and Recreation Management, no certification, work history, or eligibility, associated to becoming a qualified therapeutic recreation specialist or activities professional.

During an interview on 5/9/25, at 9:30 a.m. the Nursing Home Administrator (NHA) confirmed the facility failed to provide a qualified professional to direct the activities program as required from (4/9/24 through 5/9/25).

28 Pa Code 201.18(b)(3) Management

28 Pa Code 201.189(e)(6) Management








 Plan of Correction - To be completed: 06/25/2025

The Activity Director has enrolled in a approved activity directors program course to complete and obtain certification.

The COTA/activity aide with valid credentials will oversee the activity program until the Activity Director obtains her credentialing.
NHA/Designee reviewed requirements for current management positions and ensured credentials are in good standing.
NHA/Designee has educated the HR director on ensuring that individuals hired have the required qualifications.
NHA/Designee will confirm that licensed/certified staff have appropriate credentials upon hire.
Findings will be submitted to QAPI for review and further action if needed.

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.
Observations:
Based on review of facility policy, facility records, resident, and staff interviews, it was determined that the facility failed to make certain call bells were answered timely for five of eight residents as required (Resident R500, R503, R505, R506, and R507).

Findings include:

The facility policy "Call Light Protocol" dated 8/9/24, indicated; answer call lights in a reasonable amount of time, determine resident/patient's request, and respond to request, if unable to meet request obtain assistance from caregiver that can meet request.

During a resident group interview on 5/06/25, at 10:30 a.m., five of eight residents in attendance stated, they consistently wait one half hour or longer for their call light to be responded to. The residents in attendance expressed frustration regarding the wait time. The residents stated they have reported this at their resident council meeting.

During a resident group interview on 5/06/25, at 10:30 a.m., three of eight residents in attendance stated, their roommate consistently wait one half hour or longer for their call light to be responded to, often they will press their light to help get their roommate assistance.

Review of the 12/5/24, 1/7/25, 3/3/25, and 4/2/25 resident council meeting minutes, under the topic /concern section, reveals resident complaints regarding the call light response times and/or staff not answering the call lights.

During an interview on 5/7/25 at 1:00 p.m. the Nursing Home Administration (NHA) confirmed the facility failed to make certain call bells were answered timely for five of eight residents as required.

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

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

28 Pa Code: 201.29 (I)(o) Resident rights.





 Plan of Correction - To be completed: 06/25/2025

Current residents who are alert and oriented will be interviewed about call be ll response times.
Call lights will be answered timely per facility policy.
The DON/Designee will educate facility staff on the Call Light Policy and that it is the responsibility of all staff to respond to call lights.
DON/Designee will audit call light audits 3 times a week for 4 weeks and then one time weekly for 4 weeks. NHA/Designee will follow up with residents monthly at resident council and those who do not attend, NHA/designee will follow up with individually to ascertain call response times have improved.
Findings will be submitted to QAPI for review and further action if needed.

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
§483.12 Freedom from Abuse, Neglect, and Exploitation
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)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:
Based on review of facility policy, facility documentation and clinical record review, and staff interviews it was determined that the facility failed to investigate potential neglect for one of 11 residents (Resident R300).

Findings include:

Review of facility policy "Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin" reviewed 8/9/24, indicated reports of abuse will be promptly and thoroughly investigated. The facility should immediately report all such allegations to the Department of Health. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

Review of facility policy "Ostomy Care (Colostomy, Jejunostomy, Ileostomy, Ileo conduit)" (ostomy - surgical opening that allows waste to pass out of the body; colostomy - opening between abdomen and the colon, or large intestines; jejunostomy - opening between abdomen and middle small intestines; ileostomy.- opening between abdomen and lower small intestines.) reviewed 8/9/24, indicated the procedure for ostomy care was to maintain cleanliness and skin integrity, to prevent odors, and to prevent infections, and included the following steps:
#1 - Verify physician's orders and nursing care plan. #2 - Gather equipment, don appropriate PPE (personal protective equipment) gown, gloves, mask, face shield. #6 - Remove old appliance carefully. Warm water may loosen adhesive or a small amount of adhesive remover, if indicated. #7 - Discard old appliance in the plastic bag. Retain clamp as appropriate. #16 - Measure the stoma. #20 - Remove paper backing and position the appliance over the stoma. #23 - Dispose of used supplies in plastic bag and transport to the soiled utility room. #27 - Notify physician of any changes in stoma color or skin around stoma. #28 - Document: Date/time, color and integrity of stoma and surrounding skin, color and amount of output from stoma, and resident's tolerance to procedure. #29 - Standard precautions will be observed throughout the procedure.

The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:
13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment

Review of the clinical record indicated Resident R300 was admitted to the facility on 4/9/25, with diagnoses that included diverticulitis of large (inflammation of irregular bulging pouches in the wall of the large intestines), colostomy, and muscle weakness.

Review of the MDS dated 4/15/25 Section C Cognitive Status, Question C0500 BIMS Summary Score indicated Resident R300 BIMs was 15. Section H Bladder and Bowel; Question H0100: Appliances indicated Resident R300 had an ostomy. Section I Active Diagnoses indicated the diagnoses remain current.

Review of the physician orders revealed the following:
-On 4/9/25, change colostomy bag as needed every three days.
-On 4/9/25, colostomy care every shift and as needed.
-On 4/9/25, empty and clean colostomy bag as needed.

Review of the facility provided grievances indicated on 4/11/25 Resident R300 reported that a Licensed Practical Nurse (LPN) Employee E1 on evening shift removed his colostomy bag and threw it in the garbage. When she was unable to get another bag to fit, she removed the soiled bag from the garbage, cleaned it with bleach, and reapplied it. Resident R300 reported that although this action caused him no pain or discomfort, it did make him feel nervous.

Resident R300 was unavailable for interview.

During an observation on 5/6/25, at 9:20 a.m. with the Nursing Home Administrator, multiple sizes of ostomy supplies were noted to be in stock and available for resident use.

During a telephone interview on 5/6/25, at 10:00 a.m. LPN Employee E1 stated Resident R300's call bell was ringing for approximately one hour, and she had to go find the resident's nurse aide to go empty the colostomy bag. She stated the bag was full and almost 'bursting'. LPN Employee E1 went into the residents room to change the colostomy bag but stated she was unable to find one that fit correctly, so she removed the soiled bag from the garbage, rinsed it out with mouthwash, wiped the outside with bleach and reapplied the soiled bag to the stoma. LPN Employee E1 stated she learned to use mouthwash when she was a nurse aide to help with the smell and anti-bacterial properties. She stated that she did not ask for assistance or help when she noticed the clean ostomy bag did not fit. She denied looking for the correct supplies in the supply room.

Review of LPN Employee E1 "Skills Competency Checklist" dated 9/27/24, indicated "3" (Proficient/Expert/Highly skilled) for her nursing skill level for colostomy care and irrigation.

During an interview on 5/7/25, at 10:00 a.m. LPN Employee E2 stated she would gather supplies before entering the room to change an ostomy bag. She stated that the nurses are responsible for ostomy care, not the nurse aides.

During an interview on 5/7/25, at 10:10 a.m. LPN Employee E3 stated the ostomy supplies are located in the supply room, or in the resident's room. She stated she would gather the supplies needed before entering the resident's room to complete the ostomy bag change.

During an interview on 5/7/25, at 10:20 a.m. LPN Employee E4 stated she would gather new supplies before changing the ostomy appliance. She stated that if a size isn't listed for the order, she 'eyeballs' the stoma for sizing.

During an interview on 5/6/25, at 11:40 a.m. the Director of Nursing (DON) stated the agency LPN employee was DNR'd (Do Not Return) from the facility. The DON confirmed that the facility failed to make certain a resident was free from neglect for one resident (Resident R300).

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

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


 Plan of Correction - To be completed: 06/25/2025

Resident R300 has discharged from the facility.
NHA/Designee reviewed current resident concerns to verify reports of abuse and neglect were investigated and reported correctly.
NHA/Designee will educate staff on the facility policy for Abuse and Neglect policy and procedures.
Residents concerns that are reported, will be brought to morning meeting for the IDT to discuss and determine further action, 5x a week going forward.
Findings will be submitted to QAPI for review and further action if needed.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress.

§483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.
Observations:

Based on review of facility policy, resident clinical record, personnel record, and staff interview it was determined that the facility failed fully investigate an allegation of neglect for one out of three resident records (Resident R300).

Findings include:

Review of facility policy "Abuse, Neglect, Misappropriation of Resident Property, Injury of Unknown Origin" reviewed 8/9/24, indicated reports of abuse will be promptly and thoroughly investigated. The facility should immediately report all such allegations to the Department of Health. Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.

The "Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual," which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2019, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions:
13 - 15: cognitively intact
8 - 12: moderately impaired
0 - 7: severe impairment

Review of the clinical record indicated Resident R300 was admitted to the facility on 4/9/25, with diagnoses that included diverticulitis of large (inflammation of irregular bulging pouches in the wall of the large intestines), colostomy (surgical procedure that changes the way feces exits the body by creating an opening between the large intestines and the abdominal wall), and muscle weakness.

Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 4/15/25 Section C Cognitive Status, Question C0500 BIMS Summary Score indicated Resident R300 BIMs was 15. Section H Bladder and Bowel, Question H0100 Appliances indicated Resident R300 had an ostomy (surgically created opening in the abdomen that allows feces to pass out of the body. Section I Active Diagnoses indicated the diagnoses remain current.

Review of the physician orders revealed the following:
-On 4/9/25, change colostomy bag as needed every three days.
-On 4/9/25, colostomy care every shift and as needed.
-On 4/9/25, empty and clean colostomy bag as needed.

Review of the facility provided grievances indicated on 4/11/25 Resident R300 reported that a Licensed Practical Nurse (LPN) Employee E1 on evening shift removed his colostomy bag and threw it in the garbage. When she was unable to get another bag to fit, she removed the soiled bag from the garbage, cleaned it with bleach, and reapplied it. Resident R300 reported that although this action caused him no pain or discomfort, it did make him feel nervous.

Resident R300 was unavailable for interview.

During a telephone interview on 5/6/25, at 10:00 a.m. LPN Employee E1 stated Resident R300's call bell was ringing for approximately one hour, and she had to go find the resident ' s nurse aide to go empty the colostomy bag. She stated the bag was full and almost 'bursting'. LPN Employee E1 went into the residents room to change the colostomy bag but stated she was unable to find one that fit correctly, so she removed the soiled bag from the garbage, rinsed it out with mouthwash, wiped the outside with bleach and reapplied the soiled bag to the stoma. LPN Employee E1 stated she learned to use mouthwash when she was a nurse aide to help with the smell and anti-bacterial properties. She stated that she did not ask for assistance or help when she noticed the clean ostomy bag did not fit. She denied looking for the correct supplies in the supply room.

Review of the progress notes did not include an investigation into the neglect concerns.

Review of facility submitted reports did not include the allegation of neglect or that an investigation was completed.

During an interview on 5/6/25, at 9:00 a.m., the Director of Nursing confirmed Resident R300's incident was not recognized as neglect and therefore not fully investigated,and that witness statements were not obtained from Resident R300, other resident's, or any staff members.

28 Pa Code 201.18 (e)(1) Management

28 Pa Code 211.10 (d) Resident care policies

28 Pa Code: 201.29 (d) Resident rights





 Plan of Correction - To be completed: 06/25/2025

Resident R300 has discharged from the facility.
The concern for resident R300 was investigated and reported. Staff have been educated on proper colostomy care.
NHA/Designee reviewed current resident concerns to verify reports of abuse and neglect were investigated and reported correctly.
NHA/Designee will educate staff on the facility policy for Abuse and Neglect policy and procedures.
NHA/Designee will audit resident abuse/neglect concern investigations 3X a week for accuracy for 4 weeks and then weekly for 4 week.
Findings will be submitted to QAPI for review and further action if needed.

483.21(a)(1)-(3) REQUIREMENT Baseline Care Plan: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.
§483.21 Comprehensive Person-Centered Care Planning
§483.21(a) Baseline Care Plans
§483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must-
(i) Be developed within 48 hours of a resident's admission.
(ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to-
(A) Initial goals based on admission orders.
(B) Physician orders.
(C) Dietary orders.
(D) Therapy services.
(E) Social services.
(F) PASARR recommendation, if applicable.

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

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

Based on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop a baseline care plan for two of four residents (Resident R144 and R193).

Findings include:

Review of facility policy "Care Plan Protocol" dated 8/9/24, indicated that upon admission (unless a comprehensive POC (plan of care) is already in place a baseline poc (BPOC) will be reviewed with the resident and/or resident representative within 72 hours. The BPOC will remain in place until a comprehensive POC is completed.

Review of the clinical record indicated Resident R144 was admitted to the facility on 5/2/25,with diagnoses which included a colostomy.

Review of the clinical record failed to indicate a baseline care plan was developed for colostomy care.

Review of the clinical record indicated Resident R193 was admitted to the facility on 5/3/25, with diagnoses that included dementia (group of symptoms affecting memory, thinking and social abilities), and high blood pressure.

Review of a physician order dated 5/3/25, indicated enteral feed (tube feeding - soft, flexible, plastic tube that delivers liquid nutrition directly into the stomach or small intestines, bypassing the mouth and esophagus) continuous via NG (nasogastric tube - nose to stomach).

Review of the clinical record failed to indicate a baseline care plan was developed for tube feeding.

During an interview on 5/6/25, at 10;40 a.m., the Nursing Home Administrator confirmed that the facility failed to develop a baseline care plan within 24 hours as required for Resident R144 and R193.

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








 Plan of Correction - To be completed: 06/25/2025

Resident 144's care plan has been developed to be resident specific.
Resident 193 has discharged from the facility.
The MDS coordinator, DON, and NHA have reviewed current residents baseline care plans to verify completion.
NHA/Designee will educate Nursing supervisors, and applicable disciplines on baseline care plan regulations.
NHA/Designee will audit baseline care plans 3X a week for 4 weeks and then 1x a week for 4 weeks.
Findings will be submitted to QAPI for review and further action if needed.

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -
(i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and
(ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6).
(iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.
(iv)In consultation with the resident and the resident's representative(s)-
(A) The resident's goals for admission and desired outcomes.
(B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
§483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must-
(iii) Be culturally-competent and trauma-informed.
Observations:

Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan to meet care needs for one of five residents (Residents R142).

Findings include:

Review of facility policy "Comprehensive Care Plans" last reviewed on 8/9/25, indicated that facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with individualized needs for residents which are identified within seven days of admission.

Review of the clinical record indicated Resident R142 was admitted to the facility on 9/23/24.

Review of Resident R142's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/18/25, indicated diagnoses of legal blindness, anemia (low levels of iron in the blood), and spinal stenosis.

Review of Resident R142's plan of care dated 5/2/25, did not include development of goals and interventions to reflect the resident's blindness diagnosis.

During an interview on 5/6/25, at at 10:40 a.m., the Nursing Home Administrator confirmed Resident R142's care plan did not reflect the diagnosis of legal blindness and the facility failed develop and implement a comprehensive care plan to meet care needs for Resident R142 as required.

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

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

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



 Plan of Correction - To be completed: 06/25/2025

Resident R142's comprehensive care plan has been updated to reflect the resident's blindness diagnosis.
The MDS coordinator has reviewed current residents comprehensive care plans to ensure plans have been developed to reflect goals and interventions specific to residents with blindness diagnosis.
NHA/Designee will educate the MDS coordinator and applicable disciplines on developing personalized comprehensive care plans related to vision.
NHA/Designee will audit comprehensive care plans 2X weekly for 4 weeks and then 1X weekly for 4 weeks.
Findings will be submitted to QAPI for review and further action if needed.

483.21(b)(2)(i)-(iii) REQUIREMENT Care Plan Timing and Revision: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.
§483.21(b) Comprehensive Care Plans
§483.21(b)(2) A comprehensive care plan must be-
(i) Developed within 7 days after completion of the comprehensive assessment.
(ii) Prepared by an interdisciplinary team, that includes but is not limited to--
(A) The attending physician.
(B) A registered nurse with responsibility for the resident.
(C) A nurse aide with responsibility for the resident.
(D) A member of food and nutrition services staff.
(E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan.
(F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident.
(iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.
Observations:
Based on facility policy, clinical record review and interviews with staff, it was determined that the facility failed to revise the comprehensive care plan to reflect resident's current needs for two of eight residents (Residents R17 and R18).

Findings include:

Review of facility policy "Comprehensive Care Plans" last reviewed on 8/9/25, indicated that facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with individualized needs for residents which are identified within 7 days of admission. The care plan will be reviewed and updated as appropriate/determined by the IDT(Interdisciplinary Team) to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Review of the admission record indicated Resident R17 was admitted to the facility on 9/21/24.

Review of Resident R17's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/19/25, indicated diagnoses of Alzheimer's dementia, Diabetes and weakness.

Review of a Physician Order dated 3/7/25, indicated Resident R17 was discharged from Hospice Services due to no longer terminally ill.

Review of Resident R17's current plan of care dated 5/6/25, did not reflect the current discharge from Hospice Services status.

Review of the admission record indicated Resident R18 was admitted to the facility on 6/18/17.

Review of Resident R18's MDS dated 4/17/25, indicated diagnoses which included dementia, bipolar disorder and repeated falls.

During an observation of Resident R18's room, the resident had the bed against the wall on the right side. with a cane side rail on the left side.

Review of Resident R18's current plan of care dated 5/6/25, did not reflect the bed being against the wall per resident and family request for comfort.

During an interview on 5/9/25, at 9:35 a.m., the Nursing Home Administrator confirmed that the facility failed to revise Resident R17 and R18 's plan of care to reflect their current status as required.

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



 Plan of Correction - To be completed: 06/25/2025

Residents R17 and R18 care plans have been updated.
MDS/Designee reviewed care plans for current residents discharged from hospice services and residents with preference for bed against wall to increase mobility, to ensure care plans are accurate.
NHA/Designee will educate MDS coordinator and applicable disciplines regarding updating personalized care plans for hospice services and personal preferences.
NHA/Designee will audit 3 care plans once a week for 4 weeks and then monthly for 3 months.
Findings will be submitted to QAPI for review and further action if needed.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:
Based on review of facility policy, clinical record review, observations and staff interviews, it was determined that the facility failed to make certain that residents were provided appropriate treatment and care for one of three residents receiving enteral feedings (Resident R35).

Findings include:

Review of the facility policy "Physician Orders" dated 8/9/24, indicated that the facility will have orders for resident immediate care upon their admission to the facility.

Review of the facility policy "Enteral Feeding", dated 8/9/24, indicated that staff must verify the physician orders and prepare the feeding according to physician orders. Staff are to contact the physician and Registered Dietician to obtain orders for assure caloric needs are being met.

Review of the clinical record indicated Resident R35 was admitted to the facility on 4/15/25.

Review of Resident R35's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/18/25, indicated diagnoses of a stoke affecting her dominant side, cognitive communication deficit, dysphagia and gastrostomy for feedings.

Review of the current physician order dated May 2025, indicated Resident R35 is NPO (Nothing by mouth). Resident R35 was to receive Osmolite 1.5 at 100cc/hr nocturnal feed x 12 hours daily to go up at 9:00 p.m. and down at 9:00 a.m. with special instructions indicating Jevity 1.5 can be used when Osmolite is not available.

During an observation on 5/5/25, at 9:00 a.m., Resident R35 had a feed container indicating Jevity 1.5 was running.

During an observation on 5/6/25 at 9:00 a.m. Resident R35 again had Jevity 1.5 running.

During an interview on 5/6/25, at 9:20 a.m., the Nursing Home Administrator confirmed that Osmolite was available and that the facility failed to follow the physician order.

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

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

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





 Plan of Correction - To be completed: 06/25/2025

Resident R35 is receiving Osmolite per physician orders.
DON/Designee completed an audit on current residents who require tube feedings to confirm doctor orders are being followed.
DON/Designee will educate staff on Physician order policy and Enteral Feeding policy.
The DON/Designee will educate central supply regarding obtaining supplies/eternal feedings.
DON/Designee will audit tube feedings 2X a week for 4 weeks to confirm we are following physician orders and then weekly for 4 weeks.
Findings will be submitted to QAPI for review and further action if needed.

483.35(a)(3)(4)(c) REQUIREMENT Competent Nursing Staff: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.
§483.35 Nursing Services
The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.71.

§483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.

§483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs.

§483.35(c) Proficiency of nurse aides.
The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care.
Observations:
Based on review of facility records, employee personnel records, staff interviews, and clinical records, it was determined that the facility failed to ensure nursing staff possessed the necessary competencies and skills to provide care in accordance with the resident's care plan and individual needs to promote resident safety and comfort during care for one of four residents reviewed (Residents R300).

Findings included:

Review of facility policy "Ostomy Care (Colostomy, Jejunostomy, Ileostomy, Ileo conduit)" (ostomy - surgical opening that allows waste to pass out of the body; colostomy - opening between abdomen and the colon, or large intestines; jejunostomy - opening between abdomen and middle small intestines; ileostomy.- opening between abdomen and lower small intestines.) reviewed 8/9/24, indicated the procedure for ostomy care was to maintain cleanliness and skin integrity, to prevent odors, and to prevent infections, and included the following steps:
#1 - Verify physician's orders and nursing care plan. #2 - Gather equipment, don appropriate PPE (personal protective equipment) gown, gloves, mask, face shield. #6 - Remove old appliance carefully. Warm water may loosen adhesive or a small amount of adhesive remover, if indicated. #7 - Discard old appliance in the plastic bag. Retain clamp as appropriate. #16 - Measure the stoma. #20 - Remove paper backing and position the appliance over the stoma. #23 - Dispose of used supplies in plastic bag and transport to the soiled utility room. #27 - Notify physician of any changes in stoma color or skin around stoma. #28 - Document: Date/time, color and integrity of stoma and surrounding skin, color and amount of output from stoma, and resident's tolerance to procedure. #29 - Standard precautions will be observed throughout the procedure.

Review of the clinical record indicated Resident R300 was admitted to the facility on 4/9/25, with diagnoses that included colostomy (opening between abdomen and the colon, or large intestines) status, diverticulitis with perforation (small pouches in the walls of the colon become infected and rupture), and chronic pain.

Review of the Minimum Data Set (MDS - a mandated assessment of a resident's abilities and care needs) dated 4/15/25, indicated the diagnoses are current.

Review of the physician's orders dated 4/9/25, indicated the following:
- Change colostomy bag as needed for every three days.
-Colostomy care every shift and as needed for maintenance.
-Empty and clean colostomy bag as needed.
-Empty and clean colostomy bag every shift for maintenance.

Review of the care plan initiated 4/11/25, indicated the following interventions in place:
-Colostomy care every shift and as needed.
-Empty ostomy (surgical opening that allows waste to pass out of the body) bag every shift and as needed.
-Encourage adequate fluid intake to promote bowel movements.
-Follow up with gastroenterologist (stomach/intestine specialist) as needed/ordered.
-Monitor and record BM's (bowel movements), noting consistency and amount.
-Observe abdomen for distention, pain, bowel sounds, constipation, or no BM.
-Observe for indicators of ostomy malfunction.
-Observe for signs and symptoms of irritation, infection, and trauma around stoma,
-Ostomy care/management per orders.
- Resident has a colostomy and requires help with ostomy care and management.

Review of a facility provided grievance dated 4/11/25, indicated Resident R300 reported a concern regarding the care provided by Licensed Practical Nurse (LPN) Employee E1 on 4/10/25, evening shift. He indicated LPN Employee E1 removed his colostomy bag and threw it in the garbage. She was unable to get another bag to fit so she took the soiled colostomy bag out of the garbage, cleaned it with bleach, and reapplied it to his stoma (surgical opening that allows waste to pass out of the body). It caused him no pain or discomfort. The morning nurse on 4/11/25, retrieved the appropriate supplies and changed the colostomy bag.

Resident R300 was unavailable for interview.

During an observation on 5/6/25, at 9:20 a.m. with the Nursing Home Administrator, multiple sizes of ostomy supplies were noted to be in stock and available for resident use.

Review of facility employment records revealed agency Licensed Practical Nurse (LPN) Employee E1 completed facility policy and procedure review on 12/10/24.. Review of the staffing agency provided competency checklist dated 9/27/24, indicated LPN Employee E1 indicated a "3 - Proficient/Expert/Highly skilled)" in Colostomy Care and irrigation.

During a telephone interview on 5/6/25, at 10:00 a.m. LPN Employee E1 stated the Nurse Aide (NA) on shift 4/10/25 with her did not want to empty Resident R300's colostomy bag. "Resident R300's call light was ringing for about an hour, I had to go find the NA on duty because she wasn't on the unit." LPN Employee E1 was unable to recall the NA name because she was agency and was not familiar with the facility staff. LPN Employee E1 stated the NA told her that she did not know how to empty a colostomy bag. She stated when she entered Resident R300's room to empty the colostomy bag it was full and almost bursting, so she removed the bag and threw it in the garbage and went to the supplies in the room to get a clean bag. The supplies in the resident's room were sent with him from the hospital, but they were too big to fit the ostomy wafer (plastic rings that stick to the skin and hold the ostomy bag in place). LPN Employee E1 then removed the soiled colostomy bag from the garbage, emptied it, cleansed the outside with "a small amount of bleach" and used mouthwash to clean the inside of the bag. She stated she learned to use mouthwash and colostomy care as a nurse aid before becoming an LPN. She confirmed a Registered Nurse (RN) Supervisor was on duty but denied asking for assistance. LPN Employee E1 stated when she placed the then "clean" colostomy bag on, Resident R300 stated it did not hurt, there was no irritation or pain to the area. She stated she "just wanted the resident to be clean."

During an interview on 5/7/25, at 10:00 a.m. LPN Employee E2 stated she would gather supplies before entering the room to change an ostomy bag. She stated that the nurses are responsible for ostomy care, not the nurse aides.

During an interview on 5/7/25, at 10:10 a.m. LPN Employee E3 stated the ostomy supplies are in the supply room, or in the resident's room. She stated she would gather the supplies needed before entering the resident's room to complete the ostomy bag change.

During an interview on 5/7/25, at 10:20 a.m. LPN Employee E4 stated she would gather new supplies before changing the ostomy appliance. She stated that if a size isn't listed for the order, she 'eyeballs' the stoma for sizing.

During an interview on 5/6/25, at 11:40 a.m. the Director of Nursing confirmed the facility failed to ensure LPN Employee E1 followed the standards of practice for colostomy care for Resident R300. The staffing agency was notified to place LPN Employee E1 on the DNR (Do Not Return) list for the facility.

28 Pa. Code 201.19 Personnel policies and procedures.

28 Pa. Code 201.20 (b) Staff Development.

28 Pa. Code 211.11(d) Resident care plan.

28 Pa. Code 201.29 (c)(j) Resident Rights.

28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services.


 Plan of Correction - To be completed: 06/25/2025

Resident R300 has discharged from the facility.
DON/Designee have educated current staff on ostomy care. New hired staff will be educated prior to their first shift.
DON/Designee has completed an audit on current residents with Colostomy, Urostomy, or Illeostomy to verify that there are no concerns or issues with care.
DON/Designee will audit residents with colostomy's 3X a week for 4 weeks and then weekly for 4 week to ensure that proper supplies are available and in use.
Findings will be submitted to QAPI for review and further action if needed.

483.60(c)(1)-(7) REQUIREMENT Menus Meet Resident Nds/Prep in Adv/Followed: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(c) Menus and nutritional adequacy.
Menus must-

§483.60(c)(1) Meet the nutritional needs of residents in accordance with established national guidelines.;

§483.60(c)(2) Be prepared in advance;

§483.60(c)(3) Be followed;

§483.60(c)(4) Reflect, based on a facility's reasonable efforts, the religious, cultural and ethnic needs of the resident population, as well as input received from residents and resident groups;

§483.60(c)(5) Be updated periodically;

§483.60(c)(6) Be reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy; and

§483.60(c)(7) Nothing in this paragraph should be construed to limit the resident's right to make personal dietary choices.
Observations:
Based on a review of facility policies, documents, clinical documentation, observations and staff interview it was determined that the facility failed to assess a resident receiving enteral feedings in a timely manner and failed to approve the planned menu for four of four menu cycle weeks. (Menu Cycle Week One, Two, Three and Four).

Findings Include:

Review of the "Registered Dietician" job description provided from the facility, with a policy review date of 8/9/25, indicated that the Dietician is to implement, coordinate and evaluate the medical nutrition therapy for the residents, provide resident and family education,provide nutritional assessment and consultation to assist in planning, organizing and directing the food an nutritional services of the facility.The Dietician is to assist in developing preliminary and comprehensive assessments of the dietary needs of each resident including a written dietary plan of care that identifies the dietary problems/needs of the resident and the goals to be accomplished.

Review of the facility four week cycle menu Diet Spreadsheets revealed the corporate Registered Dietitian had not approved the menus and signed the menus currently being used in the facility.

During an interview on 5/5/25, at 10:14 a.m., the Corporate Registered Dietitian (RD) Employee E8 confirmed that the facility did not follow the approved diet spreadsheets and offer residents an alternate menu selection of similar nutritional value.

28 Pa. Code: 211.6 (a)(b) Dietary services.


 Plan of Correction - To be completed: 06/25/2025

The Registered Dietician will sign off on the current four week menu cycle.
The MD was made aware that the facility failed to have the Registered Dietician sign off on the current menu cycle.
NHA/Designee educated Dietary Manager on the regulation regarding requirements that menus meet resident needs, be prepared in advance and be followed and signed off by the dietician or other clinically qualified nutrition professional.
NHA/designee will audit the four week menu cycle for two months and quarterly going forward to confirm that the dietician has signed off on the menus.
Findings will be submitted to QAPI for review and further action if needed.

483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to maintain complete and accurate documentation for one of seven residents (Residents R144).

Findings include:

Review of the facility policy "Episodic and Narrative Documentation" dated 8/9/24, indicated that documentation will occur in the nurses progress notes to reflect a change in status, event, or notification of the responsible party or Physician. A single narrative entry will occur for the following episodes including admission, objective facts, response to treatment and resident responses.

Review of Resident R144's clinical admission record indicated that resident was admitted to the facility on 5/2/25.

Review of Resident R144's admission clinical record documentation dated 5/2/25, stated " Ileostomy present, Ileostomy stoma WNL(within normal limits). Ileostomy stoma care provided".

Review of Resident R144's physician order dated 5/6/25, did not include care for the Ileostomy.

Review of plan of care initiated on 5/2/25, did not include Ileostomy care, including specific type and size of appliance to be utilized.

During an interview 5/7/25, at 10:26: a.m. Licensed Practical Nurse (LPN) Employee E4 stated she has changed and provided care for Resident R144's colostomy several times since his admission to the facility.

Review of Resident R144's clinical progress notes did not include Ileostomy care had been provided on any date or shift from 5/3/25, through 5/6/25.

During an interview on 5/6/25, at 10:40 a.m., the Nursing Home Administrator confirmed that the facility failed to chart accurately and appropriately for Resident R144 as required.

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

28 Pa. Code: 211.5(f) Medical records.

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






 Plan of Correction - To be completed: 06/25/2025

Resident R144 orders and care plan have been updated to reflect Ileostomy care.
DON/Designee will educate nursing staff on facility's policy for Episodic and Narrative Documentation.
DON/Designee completed an audit of current residents with Uostomy care needs to confirm that documentation is complete.
DON/Designee will audit residents with Urostomy care needs and that documentation is complete and that orders and care plan are complete, 2X a week for 4 weeks.
Findings will be submitted to QAPI for review and further action if needed.

483.95(a) REQUIREMENT Communication Training: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.
§483.95(a) Communication.
A facility must include effective communications as mandatory training for direct care staff.
Observations:
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Effective Communication for two of ten staff members (Employee E12 and E13).

Findings include:

Review of facility provided documents and training records revealed the following staff members did not have documented training on the effective communication.

Nurse Aide (NA) Employee E12 had a hire date of 6/1/22, failed to have effective communication in-service education between 6/1/22, and 5/6/25.

NA Employee E13 had a hire date of 11/11/22, failed to have effective communication in-service education between 11/11/22, and 5/6/25.

During an interview on 5/8/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on effective communication for two of ten staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.


 Plan of Correction - To be completed: 06/25/2025

Current staff have completed effective communication training and those who have not will do so before their next scheduled shift.
NHA/Designee will educate Human Resource's regarding mandatory trainings for staff.
NHA/Designee completed an audit of current staff to verify that they have received Effective Communication Training.
NHA/Designee will audit 2 agency employees weekly for 4 weeks to verify that they are receiving effective communication training.
Findings will be submitted to QAPI for review and further action if needed.

483.95(d) REQUIREMENT QAPI Training: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.
§483.95(d) Quality assurance and performance improvement.
A facility must include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program as set forth at § 483.75.
Observations:
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for two of ten staff members (Employee E12 and E13).

Findings include:

Review of facility provided documents and training records revealed the following staff members did not have documented training on the QAPI program.

Nurse Aide (NA) Employee E12 had a hire date of 6/1/22, failed to have QAPI in-service education between 6/1/22, and 5/6/25.

NA Employee E13 had a hire date of 11/11/22, failed to have QAPI in-service education between 11/11/22, and 5/6/25.

During an interview on 5/8/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on the QAPI program for four of ten staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.



 Plan of Correction - To be completed: 06/25/2025

Current staff have completed QAPI training and those who have not will do so before their next scheduled shift.
NHA/Designee completed an audit of current staff to verify that they have received QAPI training.
NHA/Designee will educate Human Resource's regarding providing QAPI training to facility staff.
NHA/Designee will audit 2 employees weekly for 4 weeks to verify that they have received QAPI training.
Findings will be submitted to QAPI for review and further action if needed.

483.95(i) REQUIREMENT Behavioral Health Training: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.
§483.95(i) Behavioral health.
A facility must provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.71.
Observations:
Based on review of facility policy, personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Behavioral Health for two of ten staff members (Employee E12 and E13).

Findings include:

Review of facility provided documents and training records revealed the following staff members did not have documented training on Behavioral Health.

Nurse Aide (NA) Employee E12 had a hire date of 6/1/22, failed to have Behavioral Health in-service education between 6/1/22, and 5/6/25.

Licensed Practical Nurse (LPN) Employee E13 had a hire date of 11/11/22, failed to have Behavioral Health in-service education between 11/11/22, and 5/6/25.

During an interview on 5/8/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on Behavioral Health for three of ten staff members.

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

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

28 Pa Code: 201.20 (a)(c) Staff development.













 Plan of Correction - To be completed: 06/25/2025

Current staff have completed behavioral health training and those who have not will do so before their next scheduled shift.
NHA/Designee completed an audit of current staff to verify they have received Behavioral health training.
NHA/Designee will educate Human Resource's regarding providing Behavioral Health training to staff.
NHA/Designee will audit 2 employees weekly for 4 weeks to verify that they have received behavioral health training.
Findings will be submitted to QAPI for review and further action if needed.

§ 201.19(8) LICENSURE Personnel policies and procedures.:State only Deficiency.
(8) A copy of the final report received from the Pennsylvania State Police and the Federal Bureau of Investigation, as applicable, in accordance with the Older Adults Protective Services Act (35 P. S. §§ 10225.101-10225.5102), the Adult Protective Services Act (35 P.S. §§ 10210.101-10210.704), and applicable regulations.

Observations:
Based on review of employee files and staff interview, it was determined the facility failed complete a background check and maintain a copy of the final report received from the Federal Bureau of Investigation, as applicable, in accordance with the Older Adults Protective Services Act (35 P. S. 10225.101-10225.5102), the Adult Protective Services Act (35 P.S. 10210.101-10210.704) for one of five employee files reviewed.

Findings include:

Review of Nurse Aide Employee E7's employee file on 5/7/25, at 1:00 p.m., failed to include a copy of the final report received from the Federal Bureau of Investigation as required for employees who have not lived in Pennsylvania for the last two years.

During an interview on 5/7/25, at 2:00 p.m. the Nursing Home Administrator confirmed the facility failed to complete the required Federal Bureau of Investigation background check on Nurse Aide, Employee E7 as required.


 Plan of Correction - To be completed: 06/25/2025

Employee E7 no longer works at the facility.
NHA/Designee will educate Human Resource's on Personnel policies and procedures.
NHA/Designee completed an audit of new hires in the last 90 days to confirm that all personnel files were complete.
NHA/Designee will audit new hire files weekly for 4 weeks and then monthly for 3 months.
Findings will be submitted to QAPI for review and further action if needed.

§ 201.20(a)(2) LICENSURE Staff development.:State only Deficiency.
(2) Restorative nursing techniques.
Observations:
Based on a review of employee education records and staff interview, it was determined that the facility failed to ensure that employees completed the required annual restorative nursing techniques education for five of ten employees reviewed (Nurse Aide (NA) Employee E12 and E14, Licensed Practical Nurse(LPN) E13, E15 and E16.

Findings include:

Review of facility provided documents and training record for employees E12, E13, E14, E15 and E16 revealed the following staff members did not have documented training on restorative nursing techniques.

NA Employee E12 had a hire date of 6/1/22, failed to have restorative nursing techniques in-service education between 6/1/22, and 5/6/25.

LPN Employee E13 had a hire date of 11/11/22, failed to have effective restorative nursing techniques in-service education between 11/11/22, and 5/6/25.

NA Employee E14 had a hire date of 6/1/22, failed to have effective restorative nursing techniques in-service education between 6/1/22, and 5/13/24.

LPN Employee E15 had a hire date of 6/6/22, failed to have effective restorative nursing techniques in-service education between 6/6/22, and 5/7/24.

LPN Employee E16 had a hire date of 6/4/22, failed to have effective restorative nursing techniques in-service education between 6/4/22, and 5/6/25.

During an interview on 5/8/25, at approximately 1:00 p.m. the Nursing Home Administrator and the Director of Nursing confirmed that the facility failed to provide training on effective restorative nursing techniques in-service education for five of ten staff members.


 Plan of Correction - To be completed: 06/25/2025

Employee E12, E13, E14, E15 and E16 have completed or will complete Restorative training prior to their next shift.
NHA/designee completed an audit to verify that current staff have completed Restorative training.
NHA/Designee will educate Human Resource's on Required annual training.
NHA/Designee will audit new hires to verify that they have completed restorative training weekly for 4 weeks and then monthly for 3 months.
Findings will be submitted to QAPI for review and further action if needed.


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