Pennsylvania Department of Health
RYDAL PARK OF PHILADELPHIA PRESBYTERY HOMES INC
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RYDAL PARK OF PHILADELPHIA PRESBYTERY HOMES INC
Inspection Results For:

There are 98 surveys for this facility. Please select a date to view the survey results.

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RYDAL PARK OF PHILADELPHIA PRESBYTERY HOMES INC - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification Survey, Civil Rights Compliance Survey, State Licensure Survey and an Abbreviated survey in response to a complaint, completed on March 6, 2025, it was determined that Rydal Park of Philadelphia Presbytery Homes was not in compliance with the 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 related to the health portion of the survey process.

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 observations, interviews with staff, and a review of facility procedures, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety.

Findings include:

Review of facility policy titled, "Production, Purchasing, Storage" revised January 1015 revealed that, "All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption." Further review revealed staff must date and rotate items; first in, first out (FIFO) and discard food past the use-by or expiration date.

A tour of the main kitchen was conducted with the Food Service Director (FSD), Employee E3, on March 3, 2025, at 9:43 a.m.

The refrigerator emitted a foul sulfur odor.

Observations in the refrigerator revealed an open package of ground beef was labeled with an expiration date of February 22, 2025. Further observations revealed two 10-pound cooked, ready to eat pastrami was labeled January 17, 2025.

Further observations revealed eleven 10-20-pound beef hunks were undated and unlabeled; and four 10-pound beef briskets were unlabeled and undated.

Further observations revealed eight 10- pound lamb hunks were labeled "good through 2/19" and placed in a tall metal container. The container was filled with red colored liquid covering the lamb hunks.

Further observations revealed five 10-20- pound pork loins undated and unlabeled; two top round roast beef contained no received date.

Interview with the FSD during the kitchen tour confirmed the above-mentioned findings.

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

28 Pa. Code 201.18(b)(3) Management

Plan of Correction - To be completed: 05/05/2025

Immediate corrective action was taken to remove any product that was not labeled or expired once identified by the surveyors on March 3, 2025.

At the time of receipt products will be marked with the received by date by the designated person.

A full and comprehensive audit was completed to identify compliance with label, date, and rotation of products, any issues identified were corrected at the time of identification.

Culinary Director or designee will complete spot audits for compliance with labeling, dating, trash can coverage, and loading dock area. Audits will be completed weekly for 4 weeks then monthly for 4 months.

The Culinary Director of Dining or designee will submit the results of audits to the QAPI Committee.

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

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

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

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

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

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

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

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

Observations:

Based on observation, review of facility policy and procedure and interviews with staff, it was determined that the facility failed to maintain an effective infection control program related to the hand hygiene during medication administration, and wound treatment for two of two residents observed. (Resident R67 and Resident R57)

Findings include:

Review of "Medication Administration General Guidelines" dated May 2016, revealed that "Hands are washed with soap and water and gloves applied before administration of topical, ophthalmic, otic, parenteral, enteral, rectal and vaginal medications."

On March 6, 2023, at 9:26 a. m., observed a medication administration, dispensed by a Registered Nurse, Employee E9, to Resident R396. It was observed that Licensed nurse, Employee E5 prepared the medication, including the eye drop, placed the medication next to the resident. Employee E9 touched resident's bed side table. Once the nurse administered the oral medications, he opened an eye drop and administered the eye drop to the resident. It was observed that the employee did not was his hand or wear gloves prior to the eye drop administration.

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

Plan of Correction - To be completed: 05/05/2025

One-to-one education was provided to Employee E9 on March 5, 2025.

Nursing staff will be re-educated by DON/designee on proper handwashing and infection control best practices during medication administration.

Infection Preventionist or designee will monitor compliance with random audits weekly for 4, then month for 3 months.

ICP or designee will report the to the QAPI Committee.

483.60(i)(4) REQUIREMENT Dispose Garbage and Refuse Properly:

§483.60(i)(4)- Dispose of garbage and refuse properly.

Observations:

Based on observations and interviews with staff, it was determined that the facility did not ensure that that trash and recyclables were properly disposed of in the receiving and dumpster area.

Findings include:

A tour of the Food Service Department was conducted was conducted with the Food Service Director (FSD), Employee E3, on March 3, 2025, at 9:43 a.m., revealed the following concerns:

Observations in the receiving area revealed two grey trash cans and one blue dumpster of trash inside exposed.

Observations near the receiving door revealed four wooden pallet stacks with broken pieces, laying on the ground, approximately five feet high, three broken wooden cabinets, and broken bathroom vanity.

Interview with the FSD on March 3, 2025, at 9:55 a.m. confirmed the above findings.

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

28 Pa. Code 201.18(b)(3) Management

Plan of Correction - To be completed: 05/05/2025

Lids were placed on the trash cans in the loading dock area and the dumpster lid was closed at the time of identification by the surveyor. The wooden pallets were removed immediately on March 3, 2025.

Immediate corrective action was taken to remove any product that was not labeled or expired once identified by the surveyors on March 3, 2025.

At the time of receipt products will be marked with the received by date by the designated person.

A full and comprehensive audit was completed to identify compliance with label, date, and rotation of products, any issues identified were corrected at the time of identification.

Culinary Director or designee will complete spot audits for compliance with labeling, dating, trash can coverage, and loading dock area. Audits will be completed weekly for 4 weeks then monthly for 4 months.

The Culinary Director of Dining or designee will submit the results of audits to the QAPI Committee.

483.10(c)(1)(4)(5) REQUIREMENT Right to be Informed/Make Treatment Decisions:

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(c) Planning and Implementing Care.
The resident has the right to be informed of, and participate in, his or her treatment, including:

§483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition.

§483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care.

§483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers.

Observations:

Based on clinical record reviews and interviews with staff, it was determined that the facility failed to ensure that residents or their representatives were informed of treatment options, as well as the risks and benefits of the proposed care, for one of six residents reviewed for psychotropic medications (Residents R396).

Findings include:

Review of Resident R396's Admission MDS (Minimum Data Set - a mandatory periodic resident assessment tool), dated December 9, 2024, revealed that the resident was admitted to the facility on December 5, 2024, and had diagnoses including progressive neurological conditions and Parkinson's disease. Continued review revealed that the resident had a BIMS (Brief Interview for Mental Status) score of 12, which indicated that the resident was moderately cognitively impaired.

Review of progress notes for Resident R369 revealed a nurses note, dated December 24, 2024, which indicated that the resident had a new order for Seroquel (antipsychotic medication used to treat mood disorders).

Review of Medication Administration Records (MARs) for Resident R369 revealed that the resident received Seroquel 12.5 milligrams (mg) daily from December 24, 2024, to December 30, 2024. The medication was increased to 25 mg daily on December 31, 2024.

Further review of Resident R369's progress notes revealed no indication that the resident or her responsible party were notified of the new medication, that the risks and benefits were explained or that the resident was offered alternative treatment options.

Review of Resident R369's psychiatry note, dated December 24, 2024, revealed that the resident had agitation and combative behavior and after adding long acting Sinemet (Medication to treat Parkinson's disease), previous Sinemet regimen was resumed, and Seroquel was added. There was no documented evidence in the psychiatric progress note that the risks and benefits were explained or that the resident was offered alternative treatment options.

Interview on March 6, 2025, at 1:21 p.m. Employee E6, Nursing Supervisor, confirmed that there was no documentation available for review at the time of the survey to indicate that Resident R396 or their responsible parties were informed of their psychotropic medication addition, that the risks and benefits were explained or that they were offered alternative treatment options.

28 Pa Code 201.29(a) Resident rights

28 Pa code 211.2(d)(6) Medical Director

Plan of Correction - To be completed: 05/05/2025

Preparation and execution of this Response and Plan of Correction does not constitute an admission or agreement by HumanGood/Rydal Park Health Facility of the truth of the facts alleged or conclusions set forth in the Statement of Deficiencies and Plan of Correction. The Plan of Correction is being prepared and/or executed solely because it is required by State and Federal Law. For the purposes of any allegation that the facility is not in substantial compliance with Federal requirements of participation, the Response and Plan of Correction constitutes the facility's allegation of compliance in accordance with section 7305 of the State Operations Manual.

Resident R 396 has had his psychotropic medication reviewed by the RN Unit Manager on 3/13/2025, resident and benefits as well as alternative treatment options were discussed with POA/Spouse.

Residents who receive psychotropic medications will be reviewed to ensure risk, benefit, and treatment options are/were explained. Any issues identified will be corrected by April 15, 2025.

Education will be provided to nursing staff by the DON/Designee on Resident's right to be informed/to make treatment decisions and on the importance of proper documentation by April 15, 2025.

DON/designee will conduct weekly audits X 4 weeks of new orders and daily audits of new admission orders. Then monthly audits for 3 months.

DON/designee will submit the results of audits to the QAPI committee.

483.10(c)(7) REQUIREMENT Resident Self-Admin Meds-Clinically Approp:

§483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate.

Observations:

Based on observations, resident, and staff interviews, it was determined that the facility failed to determine the ability to self-administer medications for one of five residents reviewed for medication safety (Resident R80).

Findings include:

Review of the facility policy " Self-Administration By Resident" dated November 2017, indicates "Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process"

Review of Resident R80's physician order dated February 15, 2025, revealed an order for Timolol Maleate Ophthalmic Solution 0.5 % instill 1 drop in both eyes every morning and at bedtime for glaucoma.

Observation of Resident R80 on March 6, 2025, at 9:17 a.m. with Employee E9, Registered Nurse, revealed that the resident had a bottle of Timolol Maleate Ophthalmic Solution 0.5 % sitting on her over the bed table. Resident R80 stated she kept the eye drop on the bed side table or on the over bed table. Resident stated she did not keep it in a locked storage.

Interview with the Employee E9, Registered Nurse on March 6, 2025 stated Resident R80 self administers the eye drops and there should be an assessment for medication administration safety.

Review of Resident R80's assessments on March 6, 2025, did not to include an assessment for medication self-administration.

Interview with the Employee E6, Registered Nurse on March 6, 2025 confirmed that there was no medication self-administration assessment for Resident R80.

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

28 Pa. Code: 211.10(c)(d) Resident care policies
.
28 Pa. Code: 211.12(d)(1)(5) Nursing services.

28 Pa. Code: 211.9(a)(1) Pharmacy services.

Plan of Correction - To be completed: 05/05/2025

Resident R80 no longer resides in the community.

Residents who wish to self-administer their medications will be evaluated for appropriateness and safety. A locked storage cabinet will be provided to residents deemed appropriate to self-administer medications.

Nursing staff will be re-educated by the DON/Designee on the self-administration of medications policy.

An audit will be conducted of residents who self-administer their medications to ensure proper use, safety and storage times.

DON/designee will review new admission at time of admission for appropriateness and safety. Audit will be conducted weekly for 4 weeks, then monthly for 3 months.

DON/designee will submit the results of audits to the QAPI Committee.

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

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

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

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

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

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

Observations:

Based on the review of clinical records and interview with staff, it was determined that the facility failed to notify the resident and the resident's representative(s) of the transfer to the hospital and the reasons for the transfer to the hospital in a timely manner, in writing and in a language and manner they understood for 3 of 4 residents reviewed for hospitalizations. (Resident R1, R59, and R246)

Findings Include:

Review of nursing note for Resident R1, dated August 24, 2024, revealed that the resident was discharged to the hospital for shortness of breath.

Review of nursing note for Resident R59, dated October 27, 2024, revealed that the resident was discharged to the hospital for evaluation and treatment.

Another nursing note for Resident R59, dated November 12, 2024, revealed that the resident was discharged to the hospital for shortness of breath.

Further review revealed a nursing note for Resident R59, dated December 28, 2024, which indicated that the resident was discharged to the hospital with diabetes ketoacidosis (complication of diabetes).

Another nursing note for Resident R59, dated February 18, 2024, indicated that the resident was discharged to the hospital with Hypoxia (body deprived of adequate oxygen supply at the tissue level).

Review of nursing note for Resident R246, dated February 11, 2025, revealed that the resident was sent to the hospital for evaluation.

Review of clinical record revealed no evidence that Residents R1, R59, and R246 representatives were notified of the transfer to the hospital and the reasons for the transfer in writing, and in a language and manner they understood.

Interview with the Nursing Home Administrator, Director of Nursing, on March 5, 2025, at 2:46 p.m. confirmed that the residents' representatives were not notified of the hospital transfers and the reasons for the transfers in writing, and in a language and manner they understood. Further interview confirmed that there was no system in place regarding notifying the residents representatives, in writing, including the reasons, prior to resident transfer or discharge.

28 Pa. Code 201.14(a) Responsibility of license

28 Pa. Code 201.29(a) Resident rights

Plan of Correction - To be completed: 05/05/2025

Notification hospital transfer cannot be corrected retroactively.

A system to provide notice of transfer/discharge in writing will be developed and implemented by April 22, 2025.

NHA or designee will education the nursing, admissions, and medical record staff on the updated system.

Medical records or designee will manage and supervise the distribution of Notice of Transfer letters.

An audit of return receipt of written notices will be completed by admissions staff or designee for 4 weeks and then monthly for 3 months.

NHA/designee will submit the Results of audits to the QA Committee.

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 and staff interview, it was determined that the facility failed to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital for 3 of 4 residents reviewed for hospitalizations. (Resident R1, R59, and R246)

Findings include:

Review of nursing note for Resident R1, dated August 24, 2024, revealed that the resident was discharged to the hospital for shortness of breath.

Review of nursing note for Resident R59, dated October 27, 2024, revealed that the resident was discharged to the hospital for evaluation and treatment.

Another nursing note for Resident R59, dated November 12, 2024, revealed that the resident was discharged to the hospital for shortness of breath.

Further review revealed a nursing note for Resident R59, dated December 28, 2024, which indicated that the resident was discharged to the hospital with diabetes ketoacidosis (complication of diabetes).

Another nursing note for Resident R59, dated February 18, 2024, indicated that the resident was discharged to the hospital with Hypoxia (body deprived of adequate oxygen supply at the tissue level).

Review of nursing note for Resident R246, dated February 11, 2025, revealed that the resident was sent to the hospital for evaluation.

Further review of clinical records revealed that there was no documented evidence that the Resident and Residents' representative were provided with a written notice of the facility bed-hold policy at the time of facility-initiated transfer to the hospital for Resident R1, R59, and R246.

Interview with the Nursing Home Administrator, Director of Nursing, on March 5, 2025, at 2:46 p.m. confirmed that Resident R1, R59, and R246, and resident representatives were not provided with the bed hold policy, that included information explaining the duration of the bed-hold, bed hold reserve payment and permitting return to a bed at the facility. Further interview confirmed that there was no system in place to ensure that the resident and resident representative receive written notice of the facility bed-hold policy at the time of a facility-initiated transfer to a hospital.

28 Pa Code 201.14(a) Responsibility of licensee

28 PA Code 201.29(f) Resident rights

Plan of Correction - To be completed: 05/05/2025

Notification bed hold policy cannot be corrected retroactively.

A system to provide notice of transfer/discharge in writing will be developed and implemented by April 22, 2025.

NHA or designee will education the nursing, admissions, and medical record staff on the updated system.

Medical records or designee will manage and supervise the distribution of Notice of Transfer letters.

An audit of return receipt of written notices will be completed by admissions staff or designee for 4 weeks and then monthly for 3 months.

NHA/designee will submit the Results of audits to the QAPAI Committee.

483.24(a)(2) REQUIREMENT ADL Care Provided for Dependent Residents:

§483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene;

Observations:

Based on review of clinical record, review of facility documentation and review of facility policy, it was determined that the facility failed to ensure that a resident was transfer into bed timely as prefer by the resident for one of 21 residents sampled residents for activities of daily living (Resident R246).

Findings Include:

Review the policy title Activates of Daily Living (ADLs), supporting that was revised on March on 2018, revealed that on residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs)

Review of Resident R246's Minimum Data Set (MDS- assessment of resident's needs) dated January 6, 2025 revealed that the resident had a BIMS (Brief Interview of Mental Status) of 14, which indicated that the resident was cognitively intact. Continued review of the MDS revealed that the resident was able to chose her/his own customary preferences and the residnet required partial to moderate assistance for bed mobility.

Review faciltiy investigation initiated on January 7, 2025, revealed that the resident reported to the Social Worker that on January 7, 2025, that after lunch the team member who help her to the bathroom refused to put her in bed when she requested to go to bed.

Reviewed the witness statement from nursing aide, Employee E5 (7-3 pm day shift), from January 7, 2025, revealed that resident R246 asked to go to the bed around 3:02 p.m. yesterday. "ask her can she wait for the other shift."

Reviewed another witness statement from Register nurse, Employee E6 (3-11pm evening shift) of January 7, 2025, revealed that Employee E7 went into room to resident R246 and the resident reported that she asked earlier to be put into bed after she went to the bathroom and the person refused to take her to the bed."Resident stated that the aid told her to wait after dinner...the agency aide took her to the bathroom around 6:27 p.m."

The facility failed to ensure that Resident R246 was assisted into bed timely.

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

483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

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.

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

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

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

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

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

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

Observations:

Based on facility documentation and staff interview, it was determined that the facility failed to maintain clinical records that were accurate and complete for 21 of 21 sampled residents.

Findings include:

Review of facility document titled, "Arbitration Agreement" revealed a designated signature area and two blank check boxes indicating whether the resident agrees to "consent to arbitrate" or "do not consent to arbitrate." Further review revealed that resident signatures were present without indication of whether residents agree to arbitrate or disagree.

Interview with the Facility Administrator, on March 6, 2025, at 10:00 a.m. revealed that facility staff failed to direct residents to mark which option they prefer and required a signature of the incomplete document. Further interview confirmed that a total of 204 residents arbitration records were incomplete.

28 Pa. Code 211.5(f) Medical records.

Plan of Correction - To be completed: 05/05/2025

An audit was completed on March 10,2025 on current residents with incomplete arbitration agreements.

NHA/designee will re-educate the team responsible for admission paperwork on the completion of the arbitration agreements.

Current residents who did not previously complete the arbitration agreement will be provided with an explanation of how to complete the form by March 28, 2025.

Weekly audits of the arbitration agreements for new residents will be completed for 4 weeks, then monthly for 3 months by the NHA or designee.

NHA/designee will submit the results of audits to the QAPA Committee.

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