Pennsylvania Department of Health
SCENERY HILL HEALTHCARE AND REHABILITATION CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

SCENERY HILL HEALTHCARE AND REHABILITATION CENTER
Inspection Results For:

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SCENERY HILL HEALTHCARE AND REHABILITATION CENTER - 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 April 24, 2025, it was determined that Scenery Hill Healthcare and Rehabilitation Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.

Plan of Correction:

483.25(m) REQUIREMENT Trauma Informed Care:

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

§483.25(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 ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD) (a mental and behavioral disorder that develops related to a terrifying event) for one of 28 residents reviewed (Resident 46).

Findings include:

The facility's policy regarding trauma informed care, dated February 13, 2025, indicated that the facility will deliver care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally-competent and account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization.

A comprehensive Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 46, dated February 3, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnoses that included depression, anxiety, and PTSD. A review of Resident 46's care plan, dated August 13, 2024, indicated that the resident had PTSD, anxiety, and depression.

There was no documented evidence the facility identified Resident 46's specific triggers that could re-traumatize the resident or implement measures as to how facility staff could prevent or minimize triggers from occurring.

An interview with the Director of Nursing on April 23, 2025, at 3:19 p.m. confirmed that the facility did not identify specific triggers that may re-traumatize residents with past traumas to prevent triggers from occurring for Resident 46.

28 Pa Code 201.24(e)(4) Admission Policy.

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

28 Pa. Code 211.16(a) Social Services.

Plan of Correction - To be completed: 06/11/2025

We immediately assessed the resident as well as interviewing her for possible triggers. The resident said she prefers to talk about her experience and stated she has no triggers. A care plan for mitigation for Post Traumatic Stress Disorder (PTSD) to include the resident's preferences was developed.
The diagnosis lists for all other residents were checked for PTSD specifically, and none were found.
The diagnosis of PTSD was added to the pre-admission checklist so triggers could be addressed within the care plan upon admission.
The Social Services Director/Admission Coordinator will be educated by the Nursing Home Administrator (NHA) on the new admission checklist. New admissions will be audited by the Social Services Director for the next 30 days to ensure a diagnosis of PTSD is care planned, and triggers are addressed within. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Date of compliance: June 11, 2025.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on review of manufacturer's instructions and observations, as well as staff interviews, it was determined that the facility failed to label multidose vials of tuberculin (solution used to detect tuberculosis infection).

Findings include:

Manufacturer's instructions for Tubersol, dated November 1, 2021, indicated that a multi-dose vial of Tubersol solution should be discarded 30 days after it is opened.

Observations of the facility's medication room on April 23, 2025, at 10:39 a.m. revealed there was one opened and undated bottle of Tubersol Tuberculin injection for Mantoux TB skin test (to test for tuberculosis).

Interview with the Director of Nursing on April 23, 2025, at 3:58 p.m. confirmed that the bottle of Tubersol was not dated when it was opened and that it should have been.

28 Pa. Code 211.9(a)(1) Pharmacy Services.

28 Pa. Code 211.12(d)(1) Nursing Services.

Plan of Correction - To be completed: 06/11/2025

The undated vial of Tubersol (multidose tuberculin serum) was immediately discarded and new vials were ordered from the pharmacy.
All other vials in the medication storage room were checked, and none were found to be open and undated.
In conjunction with the pharmacy, date / expiration stickers will be placed on boxes by the pharmacy so there is a tracking system on the multidose serum.
The Director of Nursing or designee will audit the medication room for undated vials of Tubersol daily for 5 days, weekly for three weeks and monthly for one month. The results of these audits will be reviewed by the Quality Assurance Performance Improvement Committee for compliance.
Date of compliance: June 11, 2025.

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