Pennsylvania Department of Health
WINDY HILL VILLAGE OF THE PRESBYTERIAN HOMES
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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WINDY HILL VILLAGE OF THE PRESBYTERIAN HOMES - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, State Licensure Survey, and Civil Rights Compliance Survey, completed on August 02, 2024, it was determined that Windy Hill Village Of Presbyterian Homes 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 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.

§483.60(i) Food safety requirements.
The facility must -

§483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities.
(i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations.
(ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices.
(iii) This provision does not preclude residents from consuming foods not procured by the facility.

§483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Observations:

Based on observation and staff interview, it was determined the facility failed to store food and maintain food service equipment in a safe and sanitary manner and prevent the potential for food contamination in the facility's main kitchen.

Findings include:

An observation of the facility's main kitchen on July 30, 2024, at 9:37 AM revealed the following:

A speed rack located beside the ovens was observed with trays of potatoes, as well as another tray at the bottom of the rack holding a container with a variety of equipment such as spatulas, spoons, labels, and pens. The tray contained dried spills and food splatter.

A drawer unit under a preparation table across from the ovens was dusty, contained dried food debris, and food splatter.

Lower shelves of preparation and storage tables throughout the kitchen where food preparation equipment was stored were observed with dust, crumbs, and dried spills.

Flooring throughout the kitchen under preparation tables, steam tables, oven, coolers, and along wall edges, was observed with dirt and debris buildup, dried food, wrappers, soiled plastic spoon, and dried spills.

A three-tier black cart beside the dishwashing area was observed with clean plate bases and lids. The cart handles and edges of the shelves were soiled with debris and dried food.

A table where open boxes of sugar packets and hot chocolate packets were stored contained significant dust and debris behind and around the containers.

The floor of the walk-in cooler contained a buildup of dirt and debris.

The flooring in the dry storage area was significantly worn with multiple cracked tiles.

Employee 3, production manager, was observed walking in and out of the kitchen multiple times during the above observations. Employee 3 had a full beard without any covering.

A follow up observation in the main kitchen on August 1, 2024, at 12:04 PM revealed Employee 4 and Employee 5, dietary aides, working in the kitchen production area preparing lunch service trays. Employee 4 and Employee 5 both had visible facial hair without any protective covering.

The above information was reviewed with the Nursing Home Administrator and Director of Nursing on August 1, 2024, at 2:02 PM.

483.60 (i)(2) Food store, distribute, maintain, sanitary
Previously cited 8/25/23

28 Pa. Code 201.14 (a) Responsibility of licensee

Plan of Correction - To be completed: 09/10/2024

Facility conducted and completed a thorough top to bottom cleaning. The cleaning included all areas of concern, such as preparation tables, carts, racks, shelving and floors throughout the kitchen area.

In addition, replacement tile for those identified as significantly worn and cracked have been ordered and will be replaced upon receipt. A deep clean of the entire dry storage room will be completed.

Employee 3 (Production Manager) and employees 4 and 5 (dietary aides) have been counseled by the Dietary Director on the proper wear of protective facial beard covering while working and/or performing tasks in the kitchen production area.

Education was provided to the dietary department staff by the dietary director on the importance and necessity of proper cleaning techniques performance in the kitchen preparation area as well as the proper wear of protective coverings (hair nets and beard protectors) in the kitchen.

Audits of the kitchen area cleanliness and staff adherence to protective covering will be conducted twice a week for 2 (two) weeks, weekly for one month and then monthly for 2 (two) months.

Findings will be presented and discussed at the Quality Assurance Performance Improvement Committee.

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 clinical record review, observation, and resident and staff interview, it was determined that the facility failed to accommodate resident needs regarding the accessibility of a call bell for two of 17 residents reviewed (Residents 25 and 53).

Findings include:

Clinical record review for Resident 25 revealed a diagnoses list that included: a need for assistance with personal care, weakness, and contracture of the muscles.

A current care plan for Resident 25 revealed the resident is at risk for falling related to gait abnormality, a history of pain, incontinence, and other medical areas. An intervention listed on the care plan included to keep the call bell in reach.

Observation of Resident 25 on July 31, 2024, at 9:48 AM revealed he was in bed. The call bell was observed not within reach with the call bell cord tucked between the resident's right side rail and mattress and the activator hanging down under the bed almost touching the floor.

Observation of Resident 25 on August 1, 2024, at 11:10 AM revealed he was in bed. The call bell was observed out of his reach with the call bell cord tucked between the resident's right side rail and mattress and the activator was on the floor. A concurrent interview with Resident 25 revealed the resident replied, "Good question," when asked if he knew where the call bell was. The resident further attempted to access the call bell and was unable.

Employee 3, registered nurse, was advised of the finding for Resident 25 on August 1, 2024, at 11:13 AM and further assisted the resident with accessing the call bell.

Clinical record review for Resident 53 revealed a diagnoses list that included: a need for assistance with personal care, dementia, age-related physical debility, and muscle weakness.

A current care plan for Resident 53 revealed the resident is at risk for falling related to gait abnormality, cognition deficit, incontinence, attempting to crawl out of bed, and multiple other medical issues. An intervention listed on the care plan included to keep the call bell in reach.

Observation of Resident 53 on August 1, 2024, at 9:17 AM and 11:14 AM revealed she was in bed. The call bell was observed out of her immediate reach with the activator hanging down below the bed and almost touching the floor.

Employee 3, registered nurse, was advised of the finding for Resident 53 on August 1, 2024, at 11:17 AM.

The above information for Residents 25 and 53 were reviewed with the Nursing Home Administrator and Director of Nursing on August 1, 2024, at 2:05 PM.

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

Plan of Correction - To be completed: 09/10/2024

The facility accommodated Residents #25 and #53 needs regarding the accessibility of a call bell by ensuring units are firmly connected to bed units within reach of each resident.

A review and audit will be performed on remaining resident call bells to ensure all were accessible to the residents and securely connected.

An educational session was conducted by the Director of Nursing and/or designee with nursing staff on the importance of ensuring all residents have the accessibility to their call bells and the potential areas of concern if not secured and within reach.

Audits of 5 (five) residents call bell units will be conducted 3 (three) times a week for 4 (four) weeks ensuring the accessibility of the units, then 3 times monthly for 2 (two) months.

Audit tool and findings will be presented to the Quality Assurance Performance Improvement Committee for recommendations, discussion continuation, or resolution as results indicate.

483.80(d)(1)(2) REQUIREMENT Influenza and Pneumococcal Immunizations:

§483.80(d) Influenza and pneumococcal immunizations
§483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that-
(i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and
(B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal.

§483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that-
(i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization;
(ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized;
(iii) The resident or the resident's representative has the opportunity to refuse immunization; and
(iv)The resident's medical record includes documentation that indicates, at a minimum, the following:
(A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and
(B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to ensure a resident received or was offered pneumococcal conjugate vaccines for two of five residents reviewed for immunization concerns (Residents 7 and 168).

Findings include:

Clinical record review for Resident 7 revealed that the facility admitted her on March 12, 2024. Review of her immunizations in her clinical record revealed that there was no documentation related to the pneumococcal conjugate vaccines (vaccines administered to prevent pneumonia).

Clinical record review for Resident 168 revealed that the facility admitted her on July 17, 2024. Review of her immunizations in her clinical record revealed that there was no documentation related to the pneumococcal conjugate vaccines.

The Director of Nursing was made aware of concerns with Resident 7 and 168's pneumococcal vaccinations on August 2, 2024, at 1:01 PM.

The facility failed to ensure the Residents 7 and 168 received the appropriate vaccinations as recommended.

28 Pa. Code 201.14(a) Responsibility of licensee

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

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

Plan of Correction - To be completed: 09/10/2024

Both Resident #7 and Resident #168 were offered the pneumococcal conjugate vaccines. Resident #7 accepted and received the vaccine and Resident #168 refused the vaccine.

Current resident immunization records were reviewed to ensure all residents or resident representatives were offered the pneumococcal conjugate vaccines. Corrective actions were taken with any outliers upon the completion of the review. Future admissions will be offered the immunization by the Registered Nurse supervisor and documented as part of the initial assessment.

Education was provided to licensed clinical staff by the Infection Control Coordinator on the overall immunization effects on residents and necessity of ensuring the immunizations are offered appropriately to residents.

Audits will be conducted on 5 (five) random residents 3 (three) times a week for one month, and 3 (three) times monthly for two months to ensure the pneumococcal conjugate vaccine is being offered in accordance with the appropriate guidelines.

Findings will be presented to the Quality Assurance Performance Improvement Committee for discussion and further recommendations.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to identify triggers related to a resident's diagnosis of Post-Traumatic Stress Disorder, to provide culturally, competent, trauma-informed care and eliminate or mitigate re-traumatization for one of one resident reviewed (Resident 10).

Findings include:

Clinical record review for Resident 10 revealed a current care plan entitled "Behavioral Symptoms" that identified her as having PTSD (Post Traumatic Stress Syndrome, a mental and behavioral disorder that develops from experiencing a traumatic event). The care plan goal was that Resident 10 would remain stable with interventions and medications as ordered. Further review of her care plan revealed that the facility failed to identify triggers that may retraumatize her related to her diagnosis of PTSD.

A physician's progress note provided to the surveyor on August 2, 2024, at 9:30 AM dated November 24, 2004, indicated that Resident 10 was admitted from a personal care home after an alleged rape by another resident. The note also indicated that Resident 10 was in a motor vehicle accident in 1987 and suffered head trauma. Neither of the two events were identified in her plan of care as the cause of her PTSD but were provided to the surveyor as the identified cause of Resident 10's PTSD.

Interview with the Director of Nursing on August 2, 2024, at 9:45 AM confirmed the above noted findings related to Resident 10's diagnosis of PTSD.

The facility failed to identify care plan triggers that may retraumatize Resident 10 related to her diagnosis of PTSD.

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

Plan of Correction - To be completed: 09/10/2024

Staff completed a review of the Resident 10 medical record to identify triggers related to the resident' diagnosis of Post-Trauma Stress Disorder. An updated and current care plan was completed to provide the cultural, competent, trauma-informed care required to migrate this resident.

A review of current residents with the diagnosis of Post-Trauma Stress Disorder was completed. Any findings were addressed with a revised and current care plan to include potential triggers relating to the resident's diagnosis that may retraumatize the resident.

Education was provided by the Director of Nursing or designee to the clinical management team and nursing management on the basis of identifying potential triggers for residents with the diagnosis of Post-Trauma Stress Disorder.

Audits of any newly diagnosed with Post-Trauma Stress Disorder will be completed weekly for 1 (one) month and 3 (three) times monthly for 2 months. Data from any findings will be presented to the Quality Assurance Performance Improvement Committee for recommendations and further discussions.

483.20(e)(1)(2) REQUIREMENT Coordination of PASARR and Assessments:

§483.20(e) Coordination.
A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes:

§483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care.

§483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Observations:

Based on clinical record review and staff interview, it was determined that the facility failed to identify and refer a resident with a diagnosed mental disorder for level II review for one of one resident reviewed for PASRR (Pre-Admission Screening and Resident Review) compliance (Resident 10).

Findings include:

The PA-PASRR-ID form (Pennsylvania Pre-Admission Screening and Resident Review; PA-PASRR, federally required form to help ensure that all individuals are evaluated for serious mental disorder and/or intellectual disability to ensure applicants are not inappropriately placed in nursing homes for long term care) dated February 2016 and revised in September 2018, lists examples of serious mental illness including psychotic disorder and schizophrenia.

The revised PA-PASRR-ID bulletin number 01-14-13, 03-14-10, 07-14-01, 55-14-01 dated March 1, 2014, revealed that "nursing facilities are responsible for assuring the accuracy of information reported on the PA-PASRR-ID form. If the individual has a change in condition that affects target status a PA-PASRR-EV (Level II) will need to be completed. Nursing facilities will communicate the need to have a PA-PASRR-EV done by notifying the Department's (Department of Public Welfare, now the Department of Human Services) Office of Long-Term Living, Bureau of Quality and Provider Management, Division of Nursing Facility Field Operations via the MA 408 form (a form used to notify the Department of a change in a resident's target status)."

Review of the MA 408 form dated March 2020 indicates that with a change in a resident's condition (any change in the individual's condition that affects the target status) the nursing facility is to "send or fax the original form within 48 hours to their (Department of Public Welfare's) nursing facility field operations office."

Review of Resident 10's clinical record revealed a PA-PASARR dated November 24, 2004, that documented no disorders that would trigger a level II review. The assessment indicated that there were no diagnoses of neurocognitive disorders or serious mental illness, a level II review was not necessary, and to admit Resident 10 as a regular admission. The form was reviewed by the Department of Human Services (DHS) on January 5, 2005.

Resident 10's clinical record identified her as having a diagnosis of paranoid schizophrenia (a mental disorder where a person experiences fear that feeds into their delusions and hallucinations) that was added to her plan of care on January 20, 2005. There was no evidence that the facility notified the appropriate agencies related to Resident 10's identified target diagnosis.

Interview with the Director of Nursing on August 2, 2024, at 9:30 AM acknowledged the above findings for Resident 10.

28 Pa. Code 201.14 (a) Responsibility of Licensee

28 Pa. Code 211.5(f)(iv)(vi) Medical records

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

Plan of Correction - To be completed: 09/10/2024

A newly completed PASARR level II determination assessment was completed for Resident #10 to ensure the report was included in the resident's assessment, ongoing care planning and the transition of care.

A review of the PASARRs for residents admitted within the past 6 (six) months was conducted to ensure all contain the appropriate PASARRs and assessment evaluations. No records were found in error and no further actions to be taken. Future admissions or residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for Level II review will have a new PASARR completed and sent within 48 hours to the Department of Public Welfare field operations office by the Social Service Coordinator.

An education session was completed by the Director of Nursing or designee with the admission, social service on the importance and accuracy of identifying any resident changes in behavioral disorders or related conditions for Level II reviews.

Audits of any completed PASARRS based on evidence or possible serious mental disorder, intellectual disability, or a related condition for Level II changes will be reviewed monthly for 6 months.

Findings will be presented to the Quality Assurance Performance Improvement Committee for recommendations and discussion.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:

§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.

Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide a written notice of the facility's bed hold policy to the resident or responsible party for two of seven residents reviewed for hospitalizations (Residents 8 and 13).

Findings include:

Review of Resident 8's clinical record revealed that she was admitted to the hospital on July 23, 2024. Resident 8 was still hospitalized at the time of the full health survey. There was no documented evidence in Resident 8's clinical record to indicate that the facility provided her responsible party written information on the facility's bed hold policy.

Observation on August 2, 2024, at 12:15 PM confirmed that Resident 8's bed hold forms were still sitting in an envelope at the facility's front desk. Interview with the Director of Nursing on August 2, 2024, at 12:55 PM confirmed that if a resident's responsible party is unable to be contacted regarding a transfer, then the notice is sent out via the mail.

Review of Resident 13's clinical record revealed that she was admitted to the hospital on May 31, 2024. There was no documented evidence in Resident 13's clinical record to indicate that the facility provided her responsible party written information on the facility's bed hold policy.

Interview with Employee 1, admissions, on August 2, 2024, at 9:18 AM confirmed the above findings for Resident 13.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.29(f) Resident rights

Plan of Correction - To be completed: 09/10/2024

The facility provided a written notice of the facility's bed hold policy to Resident #8's responsible party and it was returned. A copy of the bed hold policy was previously sent to Resident 13's responsible party but no evidence of a returned policy is documented. Therefore, a new bed hold policy with an explanation was sent. A copy of the returned and signed policy will be filed in the resident's medical chart.
certified mailing is included in the resident's medical chart.

A review of the facility resident records who were transferred over the past 12 (twelve) months will be completed and if necessary corrective actions will be taken. Future transfers will be reviewed by the Admission Director at the morning meeting to ensure proper procedures were followed for the Bed Hold Policy program.

Education was provided by the Director of Nursing or designee on the Bed Hold Policy and process to be completed upon each transfer to the admission coordinator and the social service representative.

Audits of all transfers will be completed weekly for 4 (four) weeks and then monthly for 3 (three) months to ensure the process is being followed in accordance with the policy. The findings will be presented to the Quality Assurance Performance Improvement Committee for recommendations and discussion.

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:

Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.

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

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

§483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

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

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

Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to provide a written notice of transfer that included all the written components to the resident and/or the resident's responsible party for two of seven residents reviewed (Resident 8 and 13).

Findings include:

Review of Resident 8's clinical record revealed that the facility transferred her to the hospital on July 23, 2024. Resident 8 was still in the hospital at the time of the full health survey. There was no documented evidence that that the facility attempted to provide Resident 8's responsible party with a transfer notice that included all the required contents: State long term care appeal agency or contact and address information for the Office of the State Long-Term Care Ombudsman including email address.

Observation on August 2, 2024, at 12:15 PM confirmed that Resident 8's transfer forms were still sitting in an envelope at the facility's front desk. Interview with the Director of Nursing on August 2, 2024, at 12:55 PM confirmed that if a resident's responsible party is unable to be contacted regarding the transfer, then the notice is sent out via the mail.

Review of Resident 13's clinical record revealed that the facility transferred her to the hospital on May 31, 2024. There was no documented evidence that the facility provided Resident 13's responsible party with a transfer notice that included all the above components.

Interview with Employee 1, admissions, on August 2, 2024, at 9:18 AM confirmed the above findings for Resident 13.

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 09/10/2024

The facility provided a written Bed Hold Acknowledgement and Notice of Transfer document containing all the required elements to include: date of transfer, specific reason of discharge/transfer, location to be transferred, right to appeal process information and the information pertaining to the Office of the Long-Term Care Ombudsman to resident #8' s responsible party and it was returned. A copy of the same written Bed Hold Acknowledgement and Notice of Transfer document was previously sent to resident #13's responsible party but no evidence of a returned form is documented. Therefore, a new written Bed Hold Acknowledgement and Notice of Transfer document was sent. A copy of the returned and signed document will be filed in the resident's medical chart.

A review of the facility resident records who were transferred over the past 6 (six) months will be completed and corrective action will be taken if necessary. Future transfers will be reviewed by the Admission Director at the morning meeting (5 days per week) to ensure proper procedures were followed for the Notice Requirements before Transfer/Discharge process to include the initial notification verification, and the written notification of the transfer/discharge and the reasons for the move.

Education was provided by the Director of Nursing or designee on the Notice Requirements before Transfer/Discharge Notification Program and the process to be completed upon each transfer. Education was provided to the admission coordinator and the social service representative.

Audits of all transfers will be completed weekly for 4 (four) weeks and then monthly for 3 (three) months to ensure the process is being followed in accordance with the policy. The findings will be presented to the Quality Assurance Performance Improvement Committee for recommendations and discussion.

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