Pennsylvania Department of Health
RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER
Inspection Results For:

There are 114 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


RIVER'S EDGE REHABILITATION & HEALTHCARE CENTER - 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 and State Licensure Survey, completed on June 3, 2024, it was determined that River's Edge Rehabilitation and Healthcare Center, 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:

483.10(c)(2)(3) REQUIREMENT Right to Participate in Planning Care:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.10(c)(2) The right to participate in the development and implementation of his or her person-centered plan of care, including but not limited to:
(i) The right to participate in the planning process, including the right to identify individuals or roles to be included in the planning process, the right to request meetings and the right to request revisions to the person-centered plan of care.
(ii) The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency, and duration of care, and any other factors related to the effectiveness of the plan of care.
(iii) The right to be informed, in advance, of changes to the plan of care.
(iv) The right to receive the services and/or items included in the plan of care.
(v) The right to see the care plan, including the right to sign after significant changes to the plan of care.

§483.10(c)(3) The facility shall inform the resident of the right to participate in his or her treatment and shall support the resident in this right. The planning process must-
(i) Facilitate the inclusion of the resident and/or resident representative.
(ii) Include an assessment of the resident's strengths and needs.
(iii) Incorporate the resident's personal and cultural preferences in developing goals of care.

Observations:

Based on staff interviews, review of facility policy and the review of clinical records, it was determined that the facility failed to ensure that residents and /or their responsible parties were provided with the opportunity to participate in their care plan meetings for 4 out of 27 residents reviewed (Residents R64, R54, R85 and R69).

Findings include:

Review of the policy, "Resident/patient/Family Care Plan Conferences, " with a revision date of August 2023, indicated that it was the policy of the facility to ensure that the resident and his/her family and legal representative are part of the interdisciplinary team and participate in the development and ongoing review of the interdisciplinary plan of care. The policy also indicated that the resident/responsible party will be notified of the care plan conference and that that the method of documentation will be documented in the medical record.

Review of the clinical record for Resident R64 indicated that he resident's last care plan meeting was on held on February 13, 2023.

Review of the clinical record for Resident R54 indicated that the resident's last care plan meeting was held on April 20, 2023.

Review of the clinical record for Resident R85 indicated that the resident's last care plan meeting was held on December 20, 2023.

Review of the clinical record for Resident R69 indicated that the resident's last care plan meeting as held on December 13, 2023.

Review of the clinical record for above referenced resident provided no evidence that the residents received written or verbal notification of the meeting by facility staff, and no evidence that the resident and/or their responsible party participated in one since the above referenced date. That they were provided a copy of the plan to ensure that the resident and his/her responsible party were aware of the plan of care that was developed, participated in its development, and were included decisions related to their care, services, treatments, and discharge planning.

During and interview with the social worker (Employee E14) on June 3, 2024 at 1:46 p.m., it was confirmed that no documentation could be produced to show evidence that the facility ensured that residents and/or their responsible party received notification of a care plan meeting, were provide with the opportunity to participate, and received a copy of their plan of care as required.

28 Pa. 211.5(f) Clinical ecords

28 Pa. Code 211.12(c) Nursing services

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

Plan of Correction - To be completed: 06/28/2024

1. For residents R64, R54, R85 and R69, social worker reached out to resident and family to schedule a care conference.
2. All Residents have the potential to be affected by the deficient practice. An audit was completed of all residents to ensure that all had proper scheduling of the care conferences per facility policy going forward.
3. Care Conference Policy Reviewed. Social Services re-educated on process of scheduling care conferences.
4. Director of Social Services or designee will audit care conference schedule weekly x 4 weeks then monthly x 60 days to ensure care conferences are scheduled in a timely manner. The results of these reviews will be reported to the Quality Assurance Performance Improvement committee monthly for 3 months. 

483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):

§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Observations:

Based on staff interviews, review of facility policy and the review of the clinical record, it was determined that the facility failed to ensure that a physician was notified of a resident's refusal to take prescribed medication for 1 out of 27 residents reviewed (Resident R39).

Findings include:

Review of the facility's undated policy, "Medication/Order Availability" indicated that it was written to ensure that all residents have medications/orders administered as ordered. The policy also indicated that medications/orders are to be administered by physician order.

Review of the physician orders for Resident R39 included the diagnoses of history of falling; hypertension (high blood pressure); seizures (sudden, uncontrolled electrical disturbance in the brain which can cause changes in an individual's behavior, movements, feelings, and consciousness). and diabetes (a chronic condition that happens when you have persistently high blood sugar levels).

Review of Resident R39's May 2024 physician orders included a physician's order for the medication, Lantus (a medication prescribed for the management of the resident's diabetes). The order indicated that the resident will be administered 12 units that will be injected subcutaneously (use of a short needle to inject medication beneath the skin) at bedtime.

Review of the resident's Medication Administration Record (MAR) indicated that that the time of the administration of the medication was 9:00 p.m. Review of MAR's for the moths of March 2024 April 2024 and May 2024 indicated that the resident continuously refused to have the injection administered to him.

Review of the resident's clinical records and physician notes did not indicate that the physician was aware that the resident continuously refused his Lantus and only administered 8 dose of the medication for all three months combined.

Review of the physician's progress note dated March 27, 2024 at 10:41 a.m. indicated that he resident was seen by the physician on the above referenced date for his monthly visit. Continued review of the note indicated that the resident's diabetes was being "controlled with Lantus insulin and glipizide."

Review of the MAR for March 2024 indicated that Resident R39 refused 28 out of 31 injections of Lantus scheduled to be administered to him. The MAR for refusals was coded with the "2" which indicated "drug refused." Review of the corresponding nursing notes for the 28 days indicated that the resident refused when an attempt was made to administer it.

Review of the physician's progress note dated April 25, 2024 at 10:07 a.m. indicated that the resident was seen by the physician on the above referenced date for his monthly check up. Continued review of the note indicated that the resident's diabetes was being "controlled with Lantus insulin and glipizide."

Review of the MAR for April 2024 indicated that Resident R39 refused 28 out of 30 injections of Lantus scheduled to be administered to him. The MAR for refusals was coded with "2" which indicated "drug refused." Review of the corresponding nursing notes for the 28 days indicated that the resident refused when an attempt was made to administer it.

Review of the physician's progress note dated May 28, 2024 at 10:43 a.m. indicated that the resident was seen by the physician on the above referenced date for his monthly checkup. Continued review of the note indicated that the resident's diabetes was being "controlled with Lantus insulin and glipizide."

Review of the MAR for May 2024 indicated that Resident R39 refused 28 out of 31 injections of Lantus scheduled to be administered to him. The MAR for refusals was coded with "2" which indicated "drug refused." Review of the corresponding nursing notes for the 28 days indicated that the resident refused the medication when an attempt was made to administer it.

During an interview with the Unit Manager (Employee E11) on June 3, 2024, at 1:00 p.m. it was discussed that the resident had been refusing the medication Lantus for at least 3 months, and that the physician is writing monthly progress notes and documenting that the resident's diabetes is being controlled by Lantus insulin, despite the refusals. Employee E11 also confirmed that there was no information to produce to show evidence that nursing staff notified the physician that the resident was refusing to take the Lantus insulin that was prescribed to him.

28 Pa Code 211.10 (c) Resident care policies

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

Plan of Correction - To be completed: 06/28/2024

1. For Resident R39 MD was notified of continued refusal of medication. Resident's case was evaluated by MD. New order to D/C Insulin due to refusals and resident being clinically stable with BS being within normal range. Resident to continue glipizide.
2. All Residents have the potential to be affected by the deficient practice. An audit was completed of all residents to ensure that MD was notified of medication refusals going forward.
3. All nurses were re-educated on notifying MD/NP of medication refusals and adjusting orders accordingly.
4. Unit manager or designee will audit 3 resident's MARs weekly x 4 weeks then monthly x 60 days to ensure MD is being notified of any medication refusals. The results of these reviews will be reported to the Quality Assurance Performance Improvement committee monthly for 3 months.

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation:

§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

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

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

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

Observations:

Based on interviews, review of facility policy, review of clinical records and facility reports, it was determined that the facility failed to ensure a complete and through investigation for bruises of unknown origin for 1 out of 27 residents reviewed (Resident R69).

Findings include:

Review of the facility "Abuse, Neglect and Exploitation," policy with a review date of March 2024 indicated that the facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents including, but not limited to: resident staff or family report of physical abuse; resident report of theft of property or missing property; psychological abuse of the resident observed, physical injury of a resident, of an unknown source.

Review of Resident R69's May 2024 physician orders revealed the diagnoses of pain; delusional disorder (the individual has firmly held false beliefs); hypertension (high blood pressure) and peripheral vascular disease (a common condition in which narrowed arteries reduce the blood flow to the arms or legs).

Review of the resident's quarterly Minimum Data Set (MDS- a periodic assessment of a resident's needs) dated November 27, 2023 indicated that the resident was cognitively impaired. Review of a quarterly MDS dated May 10, 2024 also indicated that the resident was cognitively impaired.

Review of a nursing note dated December 25, 2024 at 10:00 p.m. indicated that the resident was observed by the nurse with purplish colored areas "Resident observed with purple colored area n[sicleft hand towards wrist while in hallway. vitals were assessed, supervisor immediately notified. Resident placed onto 24 hours report monitoring. Resident currently under therapy services for Upper extremities. + ROM (range of motion)."

Review of the facility investigation regarding the incident indicated that the resident reported to the nurse that the physical therapist came into her room yesterday (April 30, 2024) and that the therapist had her do exercises using her hands. The resident also reported that today (May 1, 2024) that she noticed that she was black, blue and swollen. The resident's "Injury type" on the investigation was noted as "bruises."

During an interview with the Director of Rehabilitation (Employee E15) on June 3, 2024 at 2:27 p.m. the incident, in addition to the resident's statement regarding having physical therapy the day prior to when her bruise was reviewed with the Director of Rehabilitation. The Director of Rehabilitation reported that the resident was not in therapy when the incident occurred, and that the resident was discharged from therapy on December 19, 2023. Employee E15 reported that restorative therapy plan for the resident when therapy ended included exercises for both of her arms.

Review of the investigation regarding the resident's bruising indicated that the resident was the only person interviewed and that the investigation did not show evidence that it was a complete and through investigation that ruled out abuse/neglect. Continued review of facility documentation also did not show evidence of any interviews with staff who worked the shift on which the bruises were discovered or any interviews with staff who worked any previous shifts and who may have provided care to the resident (e.g., nurses, nursing assistants) or may have witnessed interactions with the resident or could provided insight/information as to how the resident sustained bruises of unknown origin. Review of the investigation also did not show evidence that the facility confirmed that a physical therapist or anyone was in her room providing services to her the day before the bruising was found (December 24, 2023), and if so, with who, in addition to other missing pertinent information to rule out neglect/abuse.

During a discussion with the Director of Nursing on June 3, 2024, at 3:30 p.m. it was discussed that no additional information could be found in the investigation to show evidence that the facility conducted a complete and through investigation to ensure abuse/neglect was ruled out for the resident's bruises of unknown origin.

28 Pa. Code 211.12(c) Nursing services

28 Pa. Code 201.18(b)(1)(3) Management

Plan of Correction - To be completed: 06/28/2024

1. Resident 69 was assessed for bruising and no longer had any areas of concern.
2. All residents have been audited, and no other residents were identified with bruises of unknown origin.
3. Policy for Investigating bruises of unknown origin was reviewed. All nursing staff were re-educated on process of investigating bruises thoroughly.
4. DON or designee will audit all residents with incidents involving bruises weekly x 4 weeks then monthly x 60 days to ensure thorough investigation and look back is completed. The results of these reviews will be reported to the Quality Assurance Performance Improvement committee monthly for 3 months. 

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(l).

Observations:

Based on review of facility documentation, clinical record reviews, and interviews with staff, it was determined that the facility failed to notify the Office of the State Long-Term Care Ombudsman of facility-initiated emergency transfers as required for four of four records reviewed related to hospital transfers (Residents R86, R23, R83 and R92).

Findings include:

Review of facility documentation, "Hospital Tracking Portal" received June 3, 2024, revealed that 21 residents were transferred to the hospital during February 2024, 18 residents were transferred to the hospital during March 2024, and 17 residents were transferred to the hospital during April 2024.

Review of progress notes for Resident R86 revealed a note, dated February 11, 2024, at 6:48 a.m. which indicated that the resident was transferred to a local hospital emergency department via 911 due to a swollen tongue.

Review of progress notes for Resident R23 revealed a note, dated March 20, 2024, at 10:43 p.m. which indicated that the resident had low blood sugar and was ordered by the physician to be transferred to a local hospital emergency department via 911 for further evaluation.

Review of progress notes for Resident R83 revealed a note, dated February 18, 2024, at 12:25 p.m. which indicated that the resident had a change in condition, including signs of gastrointestinal bleeding, and was transferred to a local hospital emergency department for evaluation.

Review of progress notes for Resident R92 revealed a note, dated March 19, 2024, at 10:15 p.m. which indicated that the resident had altered mental status and intractable pain, and was transferred to a local hospital emergency department for evaluation and treatment.

Further review revealed that there was no indication that the Office of the State Long-Term Care Ombudsman was notified of the above facility-initiated emergency transfers for Residents R86, R23, R83 and R92.

Interview on May 31, 2023, at 1:57 p.m. the Nursing Home Administrator confirmed that the Office of the State Long-Term Care Ombudsman was not notified in a timely manner as required of facility-initiated emergency transfers.

28 Pa. Code 201.14(a) Responsibility of licensee

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

Plan of Correction - To be completed: 06/28/2024

1. All discharges and transfers of residents over the last 4 months were faxed to the state ombudsman.
2. All Residents that are transferred to the hospital or discharged have the potential to be affected by the deficient practice. All discharges and transfers of residents over the last 4 months were faxed to the state ombudsman.
3. Social Services re-educated on the process of notification of hospital transfers and discharges to the state ombudsman.
4. Director of Social Services or designee will review all hospitalizations and discharges weekly x 4 weeks then monthly x 60 days to ensure list is faxed to state ombudsman. The results of these reviews will be reported to the Quality Assurance Performance Improvement committee monthly for 3 months. 

483.21(b)(1)(3) REQUIREMENT Develop/Implement Comprehensive Care Plan:

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

Observations:

Based on observation, staff interviews, review of resident records and facility policy, it was determined that the facility failed to ensure that a comprehensive, person-centered care plan was developed for three of 27 resident records reviewed (Residents R40, R62, and R65).

Findings include

Review of the facility's care plan policy reviewed January 2023 states, "All residents admitted to the facility will have adequate person centered care plan that provide for all their needs in a timely manner.

Review of Resident R40's physician order dated December 11, 2023, instructed to administer oxygen at 2 liters a minute via nasal cannula as needed for shortness of breath. Further orders instructed to clean the O2 (oxygen) concentrator filters on Thursdays during the 11-7 shift and as needed.

Review of Resident R62's physician order dated April 30, 2024, instructed to administer oxygen at 2 liters a minute via nasal cannula continuously for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift and as needed.

Review of Resident R65 physician orders dated August 6, 2021, instructed to administer oxygen at 2 liters a minute via nasal cannula continuously for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift.

On May 29, 2024, at approximately 12:10 p.m. it was observed and confirmed with Registered Nurse Employee E7 that Residents R40, R62 and R65 O2 concentrator filters were covered with thick dust and had not been cleaned.

Further review of the above residents' clinical records revealed no plan of care was developed for the residents use and maintenance of oxygen.

Interview with Unit Manager Employee E29 on June 3, 2024 at 2:00 p.m. confirmed no care plan was developed for Residents R40, R62 and R65 related to their use of oxygen

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

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

Plan of Correction - To be completed: 06/28/2024

1. For residents R65, R40, R62 an individualized care was developed for the use and maintenance of oxygen.
2. All residents with oxygen therapy have the potential to be affected by the deficient practice. All residents with oxygen therapy were audited and individualized care plans completed.
3. The Care Plan policy was reviewed. All nurses were re-educated on residents with oxygen therapy and the importance of having individualized care plans for the use and maintenance of oxygen.
4. Unit manager or designee will audit all residents with new orders of 02 weekly x 4 weeks then monthly x 60 days to ensure individualized comprehensive care plans for 02 are in place. The results of these reviews will be reported to the Quality Assurance Performance Improvement committee monthly for 3 months.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:

Based on observations, review of clinical records, and staff interviews, it was determined that the facility failed to ensure a physician order for neurology was followed for one of 27 residents reviewed (Resident R62).

Findings include:

Review of Resident R62 clinical records revealed the resident was transferred to the hospital for right arm weakness.

Review of the hospital discharge instructions dated April 30, 2024, indicated a follow up with neurology was to be made in two weeks.

Further review of the resident's clinical record revealed no documented evidence the neurology appointment was scheduled.

This finding was confirmed with the Unit Manager on June 3, 2024, at approximately 2:15 p.m.

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

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

Plan of Correction - To be completed: 06/28/2024

1. For resident R62 Neurology appointment was scheduled.
2. All resident's requiring appointments have the potential to be affected by the deficient practice. All residents with appointments were audited to make sure that they had a scheduled date.
3. Unit clerk(s) were re-educated on scheduling resident appointments. New appointments will be monitored in clinical using appointment checklist to ensure follow through.
4. DON or designee will audit 3 new admissions weekly x 4 weeks then monthly x 60 days to ensure follow up appointments are scheduled and completed. The results of these reviews will be reported to the Quality Assurance Performance Improvement committee monthly for 3 months.

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

§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Observations:

Based on review of facility policy, observations, record review, and staff interviews, it was determined that the facility failed to provide respiratory care services consistent with professional standards of practice for three of 27 residents reviewed, (Residents R40, Resident R62, Resident R65).

Findings Include:

Review of facility policy for Oxygen Administration revised in January 2024 indicates the purpose of this policy it to safely administer oxygen to the resident. Nursing staff will be responsible the correct administration of oxygen. The same policy states when a concentrator is used to wash the filter weekly.

Review of Resident R40's physician order dated December 11, 2023, instructed to administer oxygen at 2 liters a minute via nasal cannula as needed for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift and as needed.

Review of Resident R62's physician order dated April 30, 2024, instructed to administer oxygen at 2 liters a minute via nasal cannula continuously for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift and as needed.

Review of Resident R65 physician orders dated August 6, 2021, instructed to administer oxygen at 2 liters a minute via nasal cannula continuously for shortness of breath. Further orders instructed to clean the O2 concentrator filters on Thursdays during the 11-7 shift.

On May 29, 2024, at approximately 12:10 p.m. it was observed and confirmed with Registered Nurse Employee E7 that Residents R40, R62 and R65 O2 concentrator filters were covered with thick dust and had not been cleaned.

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

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

Plan of Correction - To be completed: 06/28/2024

1. For residents R65, R40, R62 Oxygen concentrators were wiped down and filters cleaned/changed.
2. All residents using oxygen concentrators have the potential to be affected by the deficient practice. All residents using oxygen concentrators were audited to ensure they were wiped down and filters cleaned/changed.
3. Policy/Protocol was reviewed. Environmental Services and Nursing staff re-educated on process of concentrator upkeep/maintenance.
4. Environmental Services Director or designee will audit concentrators weekly x 4 weeks then monthly x 60 days to ensure they were wiped down and filters cleaned/changed. The results of these reviews will be reported to the Quality Assurance Performance Improvement committee monthly for 3 months.

483.45(a)(b)(1)-(3) REQUIREMENT Pharmacy Srvcs/Procedures/Pharmacist/Records:

§483.45 Pharmacy Services
The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse.

§483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident.

§483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-

§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility.

§483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and

§483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.

Observations:

Based on review of facility policy, review of clinical records, and staff interviews, it was determined that the facility failed to ensure the accurate acquiring, receiving, and administration of medications to meet the needs of each resident for one of 27 residents reviewed (Resident R56).

Findings Include:

Review of facility policy "Medication/Order Availability" (undated) revealed all residents should have medications/orders administered as ordered. Per review of facility policy, in the case a medication/supply is not available, and to ensure comparable alternative is provided, staff should implement the following procedures:

1. Medication/orders are to be administered per MD order
2. If medication/supply is not available in the facility, MD is to be notified
3. Resident's plan of care is to be reviewed and suggested alternative ordered and provided.
4. Order to be updated accordingly in PCC to reflect any change
5. Discuss any change in order with IDT involved in plan of care

Resident R31 was admitted to the facility on April 10, 2024 for aftercare following a fracture left hip and malignant neoplasm of the endometrium.

Review of Resident R31's physician order revealed Oxycodone HCL 5 mg was to be given every four hours as needed for moderate pain (4-6/10) to severe (7-10) pain and Methocarbamol (for pain relief) 500 mg tablets were to be given four times a day for the resident's fractured femur starting on April 11, 2024.

Review of the nursing progress note dated April 11, 2023, indicated the resident complained of pain 7/10 and the oxycodone was not available to give, and the methocarbamol 500 mg tablets was not received from the pharmacy.

Review of Resident R56's comprehensive Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated May 14, 2024, revealed the resident was admitted to the facility on May 10, 2024.

Review of Resident R56's clinical record revealed a physician order with a start date of May 11, 2024, to apply Betamethasone Dipropionate Augmented (topical medication cream used to treat eczema) to the scalp every shift for eczema (skin condition characterized by red, itchy rashes).

Review of Resident R56's medication administration record (MAR) revealed nursing staff signed out the order for Betamethasone Dipropionate Augmented as a "9" on May 11, 12, 13, 14, and 15th, 2024. Per the chart codes on the MAR "9" is code for "Other / See Nurse Notes".

Further review of Resident R56's clinical record revealed a nurses note dated May 11, 2024, by licensed nurse, Employee E10, that the facility was "awaiting pharmacy delivery" for Betamethasone Dipropionate Augmented.

Continued review of Resident R56's clinical record revealed no corresponding nurses notes on May 12, 13, 14, or 15th, 2024, regarding the Betamethasone Dipropionate Augmented.

Interview on June 3, 2024, at 10:30 a.m. with licensed nurse, Employee E10, confirmed Resident R56 did not receive the medication cream for eczema on the above dates because the facility was waiting on the pharmacy to deliver the medication. Further interview revealed the eczema cream ended up being on back order.

28 Pa Code 211.10 (c) Resident care policies

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

Plan of Correction - To be completed: 06/28/2024

1. Resident R56 was no longer in the facility at the time of completion of survey. For Resident 31, MD made aware, pharmacy contacted, and medication was changed to an available alternative.
2. All resident's have the potential to be affected by the deficient practice.
3. The medication availability policy was reviewed. All nurses were re-educated on the medication availability policy and the process of follow up when a medication is not available in the facility.
4. DON or designee will audit shift report for weekly x 4 weeks then monthly x 60 days to ensure monitoring on medications unavailable is followed up per facility policy. The results of these reviews will be reported to the Quality Assurance Performance Improvement committee monthly for 3 months

483.50(a)(1)(i) REQUIREMENT Laboratory Services:

§483.50(a) Laboratory Services.
§483.50(a)(1) The facility must provide or obtain laboratory services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services.
(i) If the facility provides its own laboratory services, the services must meet the applicable requirements for laboratories specified in part 493 of this chapter.

Observations:

Based on review of clinical records, and staff interview, it was determined that the facility failed to obtain laboratory services to meet the needs of one resident's digoxin levels per physician orders of 27 residents reviewed (Resident R55).

Findings include:

Review of Resident R55 clinical record revealed the resident was admitted to the facility on March 25, 2020, diagnosed with Atrial Fibrillation (irregular often fast heartbeat). Review of physician orders revealed the resident was ordered the medication Digoxin to treat the resident's Atrial Fibrillation.

Review of Resident R55 clinical record revealed a plan of care for Digoxin therapy that included goals that the resident would be free from discomfort or adverse reactions related to digoxin use. Interventions included serum digoxin levels monthly or as ordered by the physician and to report to the physician, suspect toxicity if anorexia, nausea, vomiting diarrhea and visual disturbances occur initiated in March 2020.

Further review of Resident R55 physician orders dated October 2020 instructed to check the resident's digoxin levels every six months. The last documented digoxin serum levels were completed in April 2023. It was confirmed with the Unit Manager, Employee E29 on June 3, 2024, at approximately 2:00 p.m. that the facility did not obtain laboratory services for Resident R55's digoxin levels.

28 Pa. Code 201.14 (a) Responsibility of licensee

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

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

Plan of Correction - To be completed: 06/28/2024

1. For resident R55, received lab work for Digoxin levels. Level was within normal limits and no clinical action needed. Digoxin levels scheduled for Q3months unless otherise noted by Physician.
2. All residents taking medication Digoxin have the potential to be affected by the deficient practice.
3. Lab protocol was updated. All nurses re-educated on the process of ordering lab work at the appropriate times for residents on Digoxin level per protocol.
4. DON or designee will audit residents on Digoxin weekly x 4 weeks then monthly x 60 days to ensure level is being obtained per protocol. The results of these reviews will be reported to the Quality Assurance Performance Improvement committee monthly for 3 months.

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