Pennsylvania Department of Health
SOUTH HILLS POST ACUTE
Patient Care Inspection Results

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SOUTH HILLS POST ACUTE
Inspection Results For:

There are  136 surveys for this facility. Please select a date to view the survey results.

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SOUTH HILLS POST ACUTE - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and an Abbreviated Survey in response to two complaints completed on May 23, 2025, it was determined that South Hills Post Acute was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.


 Plan of Correction:


483.60(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 observations and staff interview, it was determined that the facility failed to properly restrain hair to prevent the potential for cross contamination in the Main Kitchen.

Findings include:

Review of facility policy "Food Preparation and Service" reviewed 3/6/25, indicated food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food.

During an observation on 5/22/25, at 11:00 a.m. Dietary Aide Employee E7 and Volunteer Dietary Aide Employee E8, were observed in the kitchen without beard restraints.

During an interview on 5/22/25, at 11:05 a.m. the Dietary Manager Employee E9 confirmed the kitchen staff should wear beard restraints, if facial hair is present.

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



 Plan of Correction - To be completed: 06/18/2025

It is the facility's policy that all dietary staff must wear appropriate hair restraints, including beard restraints when facial hair is present, to prevent potential cross-contamination during food preparation and service.

Corrective Action for Affected Residents: On 5/22/25, Dietary Aide E7 and Volunteer Dietary Aide E8 were immediately provided with beard restraints and instructed to wear them while working in the kitchen. The Dietary Manager conducted an immediate inspection of all kitchen staff to ensure proper hair restraints were in place.

Identifying other Residents having the Potential to be Affected: All residents have the potential to be affected by this practice. On 5/22/25, the Dietary Manager conducted a facility-wide audit of all dietary staff working in food service areas to ensure compliance with hair restraint requirements.

Measures put into place or Systemic Changes: 1. The Dietary Manager and/or designee will in-service all dietary staff, including volunteers, on proper hair restraint requirements by 06/04/2025. 2. New signage has been posted at kitchen entrance points regarding mandatory hair restraint requirements. 3. A supply of disposable beard restraints has been placed at the kitchen entrance. 4. The Dietary Manager has updated the kitchen entry checklist to include verification of proper hair restraints. 5. All new dietary staff and volunteers will receive education on hair restraint requirements during orientation.

Plan to Monitor Performance: 1. The Dietary Manager or designee will conduct daily observations of dietary staff for one week, then three times per week for two weeks, then weekly for one month to ensure compliance with hair restraint requirements. 2. Random audits will be conducted by the Director of Food Service three times per week for four weeks, then monthly for three months. 3. Results of these audits will be documented on the Kitchen Sanitation Audit form. 4. Any identified issues will be addressed immediately through re-education and supervisory intervention.

The Director of Food Service will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
483.10(i)(1)-(7) REQUIREMENT Safe/Clean/Comfortable/Homelike Environment:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(i) Safe Environment.
The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

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

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

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

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

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

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

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

Based on review of facility policy, facility records, observation and resident interviews, it was determined that the facility failed to provide a safe, clean, comfortable, and homelike environment for six of fourteen residents as required (Residents R500, R501, R502, R503, R504, and R505) on two of three nursing units second and third floor.

Findings included:

Review of the facility policy "Resident Rights" dated 3/6/25, indicated the facility treat all residents with kindness, respect, and dignity.

Review of Title 42 Code of Federal Regulations Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

During a resident group interview (Residents R500, R501, R502, R503, R504, and R505) on 5/19/25, at 1:30 p.m., all six residents in attendance stated the staff rarely shut the hampers containing soiled linen. The smell of soiled linen fills the hallway, and the smell also enter residents' rooms. The residents stated that they will close the hampers and will move them to an area in the hallway away from resident rooms as much as possible. The residents stated this is not respectful to them and there is no dignity when their rooms and the hall smell especially when you are eating or have visitors. The 10/1/24 Concern Log and the 1/7/25 and 2/20/25 Resident Council Minutes reflect documentation related to the "Hampers and trash being left open". The residents stated (and the Resident Council Minutes reflect) the Director of Nursing has addressed this with the staff, and the staff is compliant for a short and then go back to leaving the hampers open with soiled linen in the hallways. Resident R504 stated, it was discussed t directly with the Director of Nursing two times over the last couple of months.

During an obsevation of the third-floor nursing unit on 5/19/25, between 11:30 a.m. through 1:00 p.m. the nursing unit had a strong odor of urine. During this time, a double-sided soiled linen cart was present in Resident R105's room, next to her bed.

During an obsevation of the third-floor nursing unit on 5/19/25, at 10:30 a.m. the nursing unit had a strong odor of urine.

During an interview on 5/23/25, at approximately 11:00 a.m., the Nursing Home Administrator confirmed the facility failed to provide a clean and homelike environment for six of fourteen residents as required and on two of three nursing units second and third floor.

28 Pa. Code: 207.2(a) Administrator's responsibility.

28 Pa. Code: 201.29(k) Resident rights.




 Plan of Correction - To be completed: 06/18/2025

It is the facility's policy to provide a safe, clean, comfortable, and homelike environment for all residents, including proper management of soiled linen and maintaining appropriate odor control throughout the facility.

Corrective Action for Affected Residents: On 5/23/25, the facility immediately addressed the concerns of Residents R500, R501, R502, R503, R504, and R505 by ensuring all soiled linen hampers were properly closed and relocated away from resident rooms. Environmental services conducted a thorough cleaning of the second and third floor units, with particular attention to eliminating odors. The facility removed all hampers on all units and educated nursing employees on proper way to handle clean and soiled linen.

Identifying other Residents having the Potential to be Affected: On 5/24/25, the Director of Environmental Services conducted a facility-wide audit of all nursing units to identify any similar issues with soiled linen management and odor control. All residents have the potential to be affected by this deficient practice.

Measures put into place or Systemic Changes: 1. The Administrator conducted an all staff in-service informing of removal of all hoppers and educated on proper soiled linen management, including: -frequency of linen collection and disposal - Proper cleaning and deodorizing procedures.

New covered hampers with self-closing lids have been installed on all units to prevent odors from escaping.

Environmental services schedules have been revised to increase frequency of linen collection and disposal.

Plan to Monitor Performance: 1. Unit Managers will audit weekly soiled linen management and odor control on their respective units daily and audit findings weekly x2 weeks then and monthly thereafter.

The unit manager and/or designee will conduct weekly random audits of all units to ensure compliance with proper linen management procedures.

Resident Council meetings will include a standing agenda item to address any concerns regarding cleanliness and odor control.

Results of all audits and resident feedback will be reviewed monthly by the Quality Assurance and Performance Improvement (QAPI) committee until substantial compliance is achieved and maintained for three consecutive months.

The Unit Manager and/or designee will report monitoring plan results to the Quality Assurance and Performance Improvement (QAPI) committee. The Quality Assurance and Performance Improvement (QAPI) committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
483.25(g)(1)-(3) REQUIREMENT Nutrition/Hydration Status Maintenance: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(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident-

§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise;

§483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health;

§483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.
Observations:
Based on review of facility policy, clinical records, observations, and staff interview, it was determined that the facility failed to ensure direct care staff were aware of residents with fluid restriction orders to make certain acceptable parameters of nutritional status were maintained for three of three residents on physician ordered fluid restrictions (Resident R61, R27, and R16).

Findings include:

The facility policy "Resident Hydration and Dehydration Prevention" dated 3/4/25, indicated physician orders to limit fluids will take priority over calculated fluid needs.

Review of the clinical record indicated Resident R61 was admitted/readmitted to the facility on 10/20/24.

Review of Resident R61's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 5/9/25, included diagnoses of cardiomyopathy (disease of the heart muscle), high blood pressure, and chronic kidney disease (gradual loss of kidney function).

Review of a physician's order dated 9/23/24, indicated a 1500 milliliter (ml) daily fluid restriction.

Review of Resident R61's plan of care for nutritional risk initiated 8/16/24, revealed a 1500 ml fluid restriction.

Review of Resident R61's plan of care for noncompliance initiated 11/23/24, revealed that Resident R61 may refuse the fluid restriction.

Review of the Kardex (document that outlines the residents' activity of daily living assistance requirements, continence levels, and behaviors, as well as physician, advanced directives, diet, and allergies) as of 5/19/25, indicted a 1500 ml fluid restriction.

Review of Resident R61's care record for 5/1/25, through 5/23/25, revealed two days of fluids consumed above the 1500 ml maximum (5/4/25, and 5/11/25).

During an observation on 5/23/25, at 10:03 a.m. Resident R61 was observed to have a large Styrofoam cup of ice water at the bedside and a thermal metal cup also filled with ice water.

During an interview on 5/23/25, at 10:06 a.m. Nurse Aide (NA) Employee E1 stated that she was not aware of any residents on her unit having a fluid restriction.

During an interview on 5/23/25, at 10:09 a.m. NA Employee E2 stated that she was not aware of any residents on her unit having a fluid restriction.

On 5/23/25, at 10:10 a.m. NA Employees E1 and E2 were informed that Residents R61 was ordered a fluid restriction.

During an interview on 5/23/25, at 10:11 a.m. Licensed Practical Nurse Employee E3 confirmed that Resident R61 was on a fluid restriction, and when asked if any other residents on the unit were ordered fluid restrictions, stated that Resident R27 was also ordered a fluid restriction. At this time, NA Employees E1 and E2 confirmed that they were unaware that Resident R27 was ordered a fluid restriction.

Review of the clinical record indicated that Resident R27 was admitted to the facility on 5/20/24.

Review of the MDS dated 5/2/25, included diagnoses of cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture) and hyponatremia (low blood sodium).

Review of a physician's order dated 11/25/24. indicated a 1500 ml daily fluid restriction.

Review of Resident R27's plan of care for nutritional risk initiated 5/22/24, revealed a 1500 ml fluid restriction.

Review of the Kardex as of 5/19/25, failed to include information related to fluid restriction.

Review of Resident R27's care record for 5/1/25, through 5/23/25, revealed four days of fluids consumed above the 1500 ml maximum (4/29/25, 5/14/25, 5/16/25, and 5/23/25).

During an observation on 5/23/25, at 10:15 a.m. Resident R27 was observed to have a large Styrofoam cup of ice water at the bedside.

Review of the clinical record indicated that Resident R16 was admitted to the facility on 3/10/21.

Review of the MDS dated 5/2/25, included diagnoses of coronary artery disease, hyponatremia, and schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized speech and behavior).

Review of a physician's order dated 3/28/24, indicated a 1200 milliliter daily fluid restriction.

Review of Resident R16's plan of care for nutritional status initiated 7/31/18, included the intervention of "fluid restrictions as ordered." Additionally, the care plan indicated that Resident R16 chooses not to follow the fluid restriction at times.

Review of the Kardex as of 5/19/25, failed to include information related to fluid restriction.

Review of Resident R16's care record failed to reveal monitoring of Resident R16's fluid intake.

During an observation on 5/23/25, at 10:30 a.m. Resident R27 was observed to have a large Styrofoam cup of ice water at the bedside.

During a group interview on 5/23/25, at 10:43 a.m. NA Employees E4, E5, and E6 stated that they were not aware of any residents on their unit having a fluid restriction. At this time, NA Employees E4, E5, and E6 were informed that Resident R27 had a fluid restriction. NA Employee E5 stated that Resident R27 drinks a lot of coffee. NA Employee E6 stated he [Resident R27] is a "coffee man."

During an interview on 5/23/25, the Director of Nursing confirmed that the fluid restriction orders should be communicated to staff. Observation of the nurse aide resident census sheets for second and third floors failed to reveal information related to fluid restrictions for Resident R61, R27, and R16.

During an interview on 5/23/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure direct care staff were aware of residents with fluid restriction orders to make certain acceptable parameters of nutritional status were maintained for three of three residents on physician ordered fluid restrictions.

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

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

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

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


 Plan of Correction - To be completed: 06/18/2025

It is the facility's policy to ensure that residents maintain acceptable parameters of nutritional status, including fluid restrictions as ordered by the physician, and that all direct care staff are aware of and follow such restrictions.

Corrective Action for Affected Residents: On 5/23/25, the Director of Nursing (DON) reviewed and updated the care plans, Kardex, and nurse aide resident census sheets for Residents R61, R27, and R16 to clearly indicate their fluid restrictions. The Registered Dietitian reviewed the fluid intake records for these residents and made appropriate recommendations.

Identifying other Residents having the Potential to be Affected: On 5/24/25, the DON and Clinical Team conducted a facility-wide audit of all current residents to identify those with physician-ordered fluid restrictions. All identified residents' care plans, Kardex, and were reviewed and updated accordingly.

Measures put into place or Systemic Changes: 1. The DON will in-service all licensed nurses and nursing assistants by 06/16/2025 on: - Importance of following fluid restrictions - Documentation requirements for fluid intake - Location and proper use of fluid restriction information in care plans, Kardex.

The Kardex system has been updated to prominently display fluid restrictions now include a section for fluid restrictions.

The facility has implemented a process for discussed during daily clinical meetings and shift-to-shift report to discuss fluid restrictions

Plan to Monitor Performance: 1. The Unit Managers will audit fluid restriction documentation weekly for two weeks, then three times per week for two weeks, then weekly for one month.

The DON or designee will conduct random interviews with direct care staff to verify knowledge of resident fluid restrictions weekly for four weeks, then monthly for two months.

The nurse will monitor each sift the allotted fluid intake for the shift and will inform the CNA.

The DON will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee monthly. The QAPI committee will review the effectiveness of interventions and make adjustments as needed until substantial compliance is achieved and maintained.
483.15(c)(2)(iii)(3)-(6)(8)(d)(1)(2); 483.21(c)(2)(i)-(iii) REQUIREMENT Discharge Process:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(iii) Information provided to the receiving provider must include a minimum of the following:
(A) Contact information of the practitioner responsible for the care of the resident.
(B) Resident representative information including contact information
(C) Advance Directive information
(D) All special instructions or precautions for ongoing care, as appropriate.
(E) Comprehensive care plan goals;
(F) All other necessary information, including a copy of the resident's discharge summary, consistent with §483.21(c)(2) as applicable, and any other documentation, as applicable, to ensure a safe and effective transition of care.

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

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

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:

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

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

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

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

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

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

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:
(i) A recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results.
(ii) A final summary of the resident's status to include items in paragraph (b)(1) of §483.20, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative.
(iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter).
Observations:
Based on a review of facility policy, clinical record reviews, and staff interview, it was determined that the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for five of six residents reviewed for hospitalization (Resident R10, R30, R61, R99, and R114).

Findings Include:

Review of federal regulation Notice of Bed-Hold Policy, indicated:
-Facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies.
-The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. Reissuance of the first notice would be required if the bed-hold policy under the State plan or the facility's policy were to change.
-The second notice must be provided to the resident, and if applicable the resident's representative, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. The notice must provide information to the resident that explains the duration of bed-hold, if any, and the reserve bed payment policy. It should also address permitting the return of residents to the next available bed.

Review of facility "Bed Hold and Return Notification" dated 3/3/25, previously reviewed 11/1/24, indicated, "You will receive a copy of this agreement upon admission, upon transfer or therapeutic leave, and if any changes are made to the state or facility policies regarding this matter."

Review of the clinical record indicated Resident R10 was admitted/readmitted to the facility on 3/12/25.

Review of Resident R10's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/5/25, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and history of a stroke.

Review of a progress note dated 8/26/24, at 8:13 p.m. indicated, "New order obtained by [Nurse Practitioner] to have resident evaluated by [hospital emergency department] for exacerbation of UTI (urinary tract infection, infection in any part of the kidneys, bladder or urethra) symptoms, with increased agitation, physical aggression." Review of resident census information revealed Resident R10 was admitted to the hospital from 8/26/24, through 9/6/24.

Further review of Resident R10's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R10 or the resident representative upon transfer to the hospital.

Review of a progress note dated 9/7/24, at 10:09 p.m. indicated that Resident R10 was transferred to the hospital for abnormal vital signs. Review of resident census information revealed Resident R10 was admitted to the hospital from 9/7/24, through 9/13/24.

Further review of Resident R10's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R10 or the resident representative upon transfer to the hospital.

Review of a progress note dated 10/14/24, at 8:27 a.m. indicated that Resident R10 was transferred to the hospital for a fever. Review of resident census information revealed Resident R10 was admitted to the hospital from 10/14/24, through 10/19/24.

Further review of Resident R10's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R10 or the resident representative upon transfer to the hospital.

Review of the clinical record indicated Resident R30 was admitted/readmitted to the facility on 3/14/25.

Review of Resident R30's MDS dated 3/21/25, included diagnoses diabetes, heart failure (a progressive heart disease that affects pumping action of the heart muscles) and a seizure disorder.

Review of a progress note dated 12/24/24, at 4:31 p.m. indicated that Resident R30 was transferred to the hospital for further evaluation. Review of resident census information revealed Resident R30 was admitted to the hospital from 12/24/24, through 1/2/25.

Further review of Resident R30's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R30 or the resident representative upon transfer to the hospital.

Review of the clinical record indicated Resident R61 was admitted/readmitted to the facility on 10/20/24.

Review of Resident R61's MDS dated 5/9/25, included diagnoses of cardiomyopathy (disease of the heart muscle), high blood pressure, and chronic kidney disease (gradual loss of kidney function).

Review of a progress note dated 9/13/24, at 2:50 p.m. indicated that Resident R61's dialysis port and dressing wer red and warm to touch, and that Resident R61 went to dialysis and the nephrologist (medical doctor specializing in kidney care) wanted her sent to the emergency room. Review of resident census information revealed Resident R61 was admitted to the hospital from 9/13/24, through 9/23/24.

Further review of Resident R61's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R61 or the resident representative upon transfer to the hospital.

Review of a progress note dated 10/18/24, at 9:17 a.m. indicated that Resident R61 was sent to the hospital related to a dialysis port infection. Review of resident census information revealed Resident R61 was admitted to the hospital from 10/18/24, through 10/22/24.

Further review of Resident R61's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R61 or the resident representative upon transfer to the hospital.

Review of the clinical record indicated Resident R99 was admitted/readmitted to the facility on 12/10/24.

Review of Resident R99's MDS dated 2/10/25, included diagnoses of coronary artery disease, high blood pressure, and pneumonia (infection that inflames the air sacs in one or both lungs).

Review of a progress note dated 12/8/24, at 11:58 p.m. indicated that Resident R99 experienced chest pain and was transferred to the emergency room. Review of resident census information revealed Resident R99 was admitted to the hospital from 12/8/24, through 12/10/24.

Further review of Resident R99's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R99 or the resident representative upon transfer to the hospital.

Review of a progress note dated 2/24/25, at 10:24 p.m. indicated that Resident R99 experienced chest pain and was transferred to the emergency room. Review of resident census information revealed Resident R99 was admitted to the hospital from 2/24/25, through 3/1/25.

Further review of Resident R99's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R99 or the resident representative upon transfer to the hospital.

Review of the clinical record indicated Resident R114 was admitted/readmitted to the facility on 5/6/25.

Review of Resident R114's MDS dated 2/10/25, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat), hemiplegia (paralysis on one side of the body), and malnutrition (lack of sufficient nutrients in the body).

Review of a progress note dated 2/15/25, at 11:45 a.m. indicated that Resident R114 had a swollen tongue and was unable to speak or swallow. Resident R114 was transferred to the emergency room. Review of resident census information revealed Resident R114 was admitted to the hospital from 2/15/25, through 2/22/25.

Further review of Resident 114's clinical record failed to reveal notation that the written notice of bed hold notification was provided to Resident R114 or the resident representative upon transfer to the hospital.

During an interview on 5/23/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for five of six residents reviewed for hospitalization.

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

28 Pa Code: 201.29(f)(g) Resident rights.



 Plan of Correction - To be completed: 06/18/2025

It is the facility's policy to provide written bed-hold notification to residents and/or their representatives at the time of transfer to the hospital, in accordance with F483.15(d).

Corrective Action for Affected Residents: On 5/23/25, the Director of Nursing reviewed the medical records of Residents R10, R30, R61, R99, and R114. Written bed-hold notifications were provided to these residents and/or their representatives, documenting the facility's bed-hold policy and duration.

Identifying other Residents having the Potential to be Affected: On 5/24/25, the Director of Nursing conducted an audit of all residents transferred to the hospital within the past 90 days to identify any additional residents affected by this practice. Any identified residents without proper bed-hold documentation received written notification of the facility's bed-hold policy.

Measures put into place or Systemic Changes: 1. The DON will in-service all Licensed nurses by 06/18/2025 on: - Proper documentation of bed-hold notification - Requirements for providing written bed-hold notice upon transfer - Location of bed-hold forms in the facility - Process for documenting bed-hold notification in the medical record

The facility's transfer checklist has been updated to include bed-hold notification as a required step.

A new bed-hold notification tracking log has been implemented at each nurses' station.

Plan to Monitor Performance: 1. The Unit Managers and or designee will audit any hospital transfers weekly for 2 weeks to ensure bed-hold notifications are provided and documented then will be audited monthly x 1 month.

The Director of Nursing or designee will review audit results weekly and address any identified issues immediately through staff re-education or disciplinary action as needed.

The Quality Assurance Coordinator will report audit findings to the Quality Assurance Performance Improvement (QAPI) committee monthly for 1 month. The QAPI committee will evaluate the effectiveness of the interventions and make additional recommendations as needed until substantial compliance is achieved and maintained.
483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors: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.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations:
Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that residents are free of significant medication errors for two of three residents (Resident R24 and R63).

Findings include:

Review of the United States Food and Drug Administration prescribing information dated 09/2017, indicated Coreg (carvedilol) is an alpha-/beta-adrenergic blocking agent indicated for the treatment of mild to severe chronic heart failure, left ventricular dysfunction following myocardial infarction in clinically stable patients, and hypertension. Listed in the adverse reactions / side effects were bradycardia (low heart rate) and hypotension (low blood pressure).

Review of facility policy "Administering Medications" reviewed dated 3/3/25, previously reviewed 11/1/24, indicated medications are administered in accordance with prescriber orders.

Review of the clinical record indicated Resident R24 was admitted to the facility on 7/3/21.

Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 3/5/25, included diagnoses of end stage renal disease (ESRD, an inability of the kidneys to filter the blood), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and high blood pressure.

Review of the physician order dated 1/13/23, indicated to give Resident R24 Coreg (blood pressure medication) 3.125 milligrams twice daily, and to hold for a systolic blood pressure (SBP) of less than 110 or a heart rate of less than 60 beats per minute.

Review of Resident R24 ' s plan of care for cardiac disease initiated 7/4/21, indicated to administer medication per physician order.

Review of Resident R24 ' s Medication Administration Records from 3/1/25, through 5/23/25, revealed the following:

03/04/25: SBP of 102, medication administered (evening dose).
03/10/25: SBP of 96, medication administered (morning dose).
03/04/25: SBP of 102, medication administered (evening dose).
03/16/25: SBP of 100, medication administered (evening dose).
03/17/25: SBP of 106, medication administered (evening dose).
03/19/25: SBP of 109, medication administered (evening dose).
03/21/25: SBP of 100, medication administered (morning dose).
03/21/25: SBP of 106, medication administered (evening dose).
03/17/25: SBP of 106, medication administered (evening dose).
03/26/25: SBP of 89, medication administered (evening dose).
03/28/25: SBP of 103, medication administered (evening dose).
04/01/25: SBP of 97, medication administered (morning dose).
04/05/25: SBP of 98, medication administered (morning dose).
04/06/25: SBP of 104, medication administered (morning dose).
04/06/25: SBP of 98, medication administered (evening dose).
04/07/25: SBP of 107, medication administered (evening dose)
04/10/25: SBP of 97, medication administered (morning dose).
04/12/25: SBP of 108, medication administered (morning dose).
04/15/25: SBP of 100, medication administered (morning dose).
04/19/25: SBP of 103, medication administered (morning dose).
04/22/25: SBP of 108, medication administered (morning dose).
04/22/25: SBP of 102, medication administered (evening dose).
04/24/25: SBP of 109, medication administered (morning dose).
04/25/25: SBP of 108, medication administered (morning dose).
04/29/25: SBP of 108, medication administered (evening dose).
05/12/25: SBP of 109, medication administered (morning dose).
05/14/25: SBP of 108, medication administered (morning dose).
05/16/25: SBP of 109, medication administered (morning dose).

Review of the clinical record indicated Resident R63 was admitted to the facility on 5/21/19.

Review of the MDS dated 5/2/25, included diagnoses of coronary artery disease (damage or disease in the heart's major blood vessels), diabetes, and high blood pressure.

Review of the physician order dated 3/9/25, indicated to give Resident R63 Coreg 3.125 milligrams twice daily, and to hold for a heart rate of less than 60 beats per minute.

Review of Resident R63 ' s plan of care for cardiac disease initiated 4/10/24, indicated to administer medication per physician order.

Review of Resident R63 ' s Medication Administration Records from 11/1/24, through 5/23/25, revealed the following:
11/27/24: heart rate 55 beats per minute, medication administered (morning dose).
12/02/24: heart rate 48 beats per minute, medication administered (morning dose).
12/04/24: heart rate 49 beats per minute, medication administered (morning dose).
12/05/24: heart rate 50 beats per minute, medication administered (morning dose).
12/07/24: heart rate 55 beats per minute, medication administered (morning dose).
12/08/24: heart rate 53 beats per minute, medication administered (morning dose).
12/10/24: heart rate 56 beats per minute, medication administered (morning dose).
12/11/24: heart rate 53 beats per minute, medication administered (morning dose).
12/12/24: heart rate 50 beats per minute, medication administered (morning dose).
12/13/24: heart rate 54 beats per minute, medication administered (morning dose).
12/16/24: heart rate 54 beats per minute, medication administered (morning dose).
12/18/24: heart rate 52 beats per minute, medication administered (morning dose).
12/21/24: heart rate 52 beats per minute, medication administered (morning dose).
12/22/24: heart rate 53 beats per minute, medication administered (morning dose).
01/08/25: heart rate 53 beats per minute, medication administered (morning dose).
01/09/25: heart rate 54 beats per minute, medication administered (morning dose).
01/10/25: heart rate 52 beats per minute, medication administered (morning dose).
01/13/25: heart rate 56 beats per minute, medication administered (morning dose).
01/19/25: heart rate 55 beats per minute, medication administered. (morning dose)
01/23/25: heart rate 56 beats per minute, medication administered (morning dose).
01/27/25: heart rate 55 beats per minute, medication administered (morning dose).
01/29/25: heart rate 57 beats per minute, medication administered (morning dose).
01/30/25: heart rate 54 beats per minute, medication administered (morning dose).
02/01/25: heart rate 49 beats per minute, medication administered (morning dose).
02/15/25: heart rate 52 beats per minute, medication administered (morning dose).
03/01/25: heart rate 54 beats per minute, medication administered (morning dose).
03/02/25: heart rate 56 beats per minute, medication administered (morning dose).
03/07/25: heart rate 54 beats per minute, medication administered (morning dose).
03/14/25: heart rate 57 beats per minute, medication administered (morning dose).
03/16/25: heart rate 58 beats per minute, medication administered (morning dose).

During an interview on 5/23/25, at approximately 12:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to make certain that residents are free of significant medication errors for two of three residents.

28 Pa. Code 207.2(a) Administrator's responsibility.

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: 06/18/2025

It is the facility's policy to ensure that residents are free from significant medication errors and that medications are administered in accordance with physician orders, including parameters for holding medications.

Corrective Action for Affected Residents: On 5/23/25, the Director of Nursing (DON) reviewed and discontinued the current Coreg orders for R24 and R63. The DON contacted the attending physicians to review medication administration records and obtain new orders. The physicians reviewed both residents' vital signs trends and medication administration history. New medication orders were obtained with clarified parameters. Licensed nurses completed comprehensive nursing assessments of both residents, including vital sign monitoring. No adverse effects were identified.

Identifying other Residents having the Potential to be Affected: On 5/24/25, the Director of Nursing and/or Unit Managers conducted an audit of all current residents receiving medications with specific vital sign parameters to identify any similar issues. The audit included review of medication administration records for the past 2 weeks to ensure compliance with hold parameters.

Measures put into place or Systemic Changes: 1. By 06/16/25, the DON and/or designee will in-service all Licensed nurses on: - Proper medication administration including adherence to vital sign parameters - Review of facility policy on medication administration - Documentation requirements for held medications - Process for notifying physicians when medications are held - Importance of following hold parameters for resident safety



Plan to Monitor Performance: 1. The Unit Managers or designee will conduct weekly audits of medication administration records for residents receiving medications with vital sign parameters for 4 weeks then monthly for 2 months

The DON or designee will review 3 medication administration records weekly for 1 month to ensure compliance with medication hold parameters.

Results of these audits will be reported to the Quality Assurance and Performance Improvement (QAPI) committee monthly for review and recommendations. The QAPI committee will determine the need for ongoing monitoring based on audit results.
483.10(g)(5)(i)(ii) REQUIREMENT Required Postings:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.10(g)(5) The facility must post, in a form and manner accessible and understandable to residents, resident representatives:
(i) A list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, adult protective services where state law provides for jurisdiction in long-term care facilities, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit; and
(ii) A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements (42 CFR part 489 subpart I) and requests for information regarding returning to the community.
Observations:
Based on observations and staff interview, it was determined that the facility failed to post complete contact information for Adult Protective Services and the State Long-Term Care Ombudsman program as required, on three of three nursing units (First Floor, Second Floor, and Third Floor nursing units).

Findings include:

During observations completed on 5/21/25, of the First Floor, Second Floor, and Third Floor nursing units failed to reveal the address and email contact information for Adult Protective Services and the Office for the State Long-Term Care Ombudsman program posted in a form and manner accessible and understandable to residents or resident representatives.

During interview, on 5/22/25, at 8:20 a.m., the Nursing Home Administrator confirmed that the facility failed to post complete contact information for Adult Protective Services and the State Long-Term Care Ombudsman program as required, on three of three nursing units.

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

28 Pa. Code: 201.18(e) Management.



 Plan of Correction - To be completed: 06/18/2025

Corrective Action for Affected Residents: On 5/22/25, the Administrator posted complete contact information, including mailing addresses, email addresses, and telephone numbers for Adult Protective Services and the State Long-Term Care Ombudsman program on all three nursing units (First Floor, Second Floor, and Third Floor).

Identifying other Residents having the Potential to be Affected: All residents have the potential to be affected by this practice. The Administrator conducted a facility-wide audit on 5/22/25 to ensure all required contact information for pertinent State agencies and advocacy groups was properly posted and complete on all units.

Measures put into place or Systemic Changes: The Administrator will in-service all department managers by 6/4/2025 on the requirement to maintain complete and accurate posting of contact information for all pertinent State agencies and advocacy groups. The Environmental Services Director or designee will create and implement a monthly checklist to verify the presence and accuracy of all required postings. The Administrator will review and update contact information quarterly or sooner if changes occur.

Plan to Monitor Performance: The Environmental Services Director or designee will audit all required postings weekly for 2 weeks, then monthly for 2 months to ensure compliance. The Administrator will validate these audits monthly. Any identified issues will be corrected immediately. The Administrator will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
483.10(g)(10)(11) REQUIREMENT Right to Survey Results/Advocate Agency Info:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.10(g)(10) The resident has the right to-
(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and
(ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies.

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

Based on observations and staff interview, it was determined the facility failed to ensure postings of the location Department of Health most recent survey results were readily accessible to residents and visitors, for three of three locations (nursing units first, second, and third).

Findings Include:

During an observation on 5/19/25, at 10:20 a.m., no postings were observed in the facility identifying the location of the Department of Health's most recent survey results.

During an interview on 5/22/25, at 8:20 a.m. the Nursing Home Administrator confirmed the facility failed to ensure postings of the location Department of Health most recent survey results were readily accessible to residents and visitors, for three of three locations (nursing units first, second, and third).

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








 Plan of Correction - To be completed: 06/18/2025

Corrective Action for Affected Residents: On 5/22/25, the Administrator posted notices in all three nursing units (first, second, and third floors) clearly identifying the location of the Department of Health's most recent survey results. The notices were placed in prominent, readily accessible areas where residents, family members, and visitors can easily locate them.

Identifying other Residents having the Potential to be Affected: All residents have the potential to be affected by this deficient practice. The Administrator conducted a facility-wide audit on 5/22/25 to ensure proper posting of all required notices and survey results.

Measures put into place or Systemic Changes: 1. The Administrator will in-service all staff by 06/4/2025 on the requirements for posting survey results and advocate agency information. 2. A new facility policy was developed on 5/22/25 designating specific locations for required postings and establishing a monthly review process. 3. The Administrator and/or designee will conduct weekly checks of all posting locations to ensure compliance. 4. A posting checklist was created and implemented to track required notices and their locations.

Plan to Monitor Performance: 1. The administrator and/or designee will audit all three nursing units weekly for 2 weeks, then monthly for 2 months to ensure proper posting of survey results and notices. 2. The Administrator and/or designee will conduct random audits of posting compliance twice monthly for 2 months. 3. Any identified issues will be corrected immediately and reported to the Administrator. 4. The Social Services Director will report monitoring results to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor on an ongoing basis until substantial compliance of the set-forth protocol is achieved.
483.10(g)(13) REQUIREMENT Posting/Notice of Medicare/Medicaid on Admit:Least serious 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 has the potential for causing no more than a minor negative impact on the resident.
§483.10(g)(13) The facility must display in the facility written information, and provide to residents and applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.
Observations:
Based on observations and staff interview, it was determined that the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, on three of three nursing units (First Floor, Second Floor, and Third Floor nursing units).

Findings include:

During observations completed on 5/21/25, of the First Floor, Second Floor, and Third Floor nursing units failed to include information on how to apply for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid.

During interview, on 5/22/25, at 8:20 a.m., the Nursing Home Administrator confirmed that the facility failed to display written information on applying for Medicare and Medicaid benefits and receiving refunds for previous payments covered by Medicare and Medicaid as required, on three of three nursing units.

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

28 Pa. Code: 201.18(e) Management.


 Plan of Correction - To be completed: 06/18/2025

Corrective Action for Affected Residents: On 5/22/25, the Administrator posted written information regarding Medicare and Medicaid benefits application processes and refund procedures on all three nursing units (First Floor, Second Floor, and Third Floor). The posted information includes detailed instructions on how to apply for and use Medicare and Medicaid benefits, and the process for receiving refunds for previous payments covered by these benefits.

Identifying other Residents having the Potential to be Affected: All current residents and potential applicants for admission have the potential to be affected by this deficient practice. The Administrator conducted a facility-wide audit on 5/22/25 to ensure proper posting of Medicare and Medicaid information in all required areas.

Measures put into place or Systemic Changes: The Administrator will in-service all Admissions staff and Social Services staff by 06/03/2025 on the requirement to maintain posted Medicare and Medicaid information in all nursing units. The in-service will include the proper location for posting information and the content requirements for Medicare and Medicaid benefit information.

A new facility policy has been implemented requiring monthly checks of all posted Medicare and Medicaid information to ensure continued compliance. The Social Services Director will be responsible for conducting these checks.

Plan to Monitor Performance: The Social Services Director will audit all three nursing units weekly for four weeks, then monthly for three months to ensure Medicare and Medicaid information remains properly posted and current. Results of these audits will be documented on a compliance monitoring tool.

The Administrator will review the audit results monthly and report findings to the Quality Assurance and Performance Improvement (QAPI) committee. The QAPI committee will monitor compliance until substantial compliance is achieved and maintained for three consecutive months.

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