Pennsylvania Department of Health
 QUALITY LIFE SERVICES - SUGAR CREEK
Patient Care Inspection Results

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QUALITY LIFE SERVICES - SUGAR CREEK
Inspection Results For:

There are  133 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.
QUALITY LIFE SERVICES - SUGAR CREEK - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance Survey completed on May 16, 2025, it was determined that Quality Life Services Sugarcreek 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 but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.60(i) Food safety requirements.
The facility must -

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

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

Based on a review of facility policy, observation and staff interview, it was determined that the facility failed to properly maintain cleanliness and sanitation of the Main Kitchen. (Main Kitchen).

Findings include:

Review of facility policy "Food Safety and Sanitation", dated 3/17/25, indicated that all local, state and federal standards and regulations are followed in order to assure a safe and sanitary food services department.

During an observation of the main designated kitchen on 5/15/25, at 11:35 a.m. the following was observed:
- Wall behind Cook's preparation area, build-up of food spillage/brown debris
- Wall behind Robocoupe (food processor)/blender area, build-up of food spillage/brown debris
- Wall behind garbage can located next to steamer, build-up of food spillage/brown debris

During an interview conducted 5/15/25, at 11:36 a.m., Registered Dietitian (RD) Employee E13 confirmed that the facility failed to properly maintain cleanliness and sanitation of the Main Kitchen. (Main Kitchen).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.


 Plan of Correction - To be completed: 07/02/2025

1.The walls behind the Cook's prep area and Robocoupe food processor, and garbage can near steam table were cleaned and sanitized at the time of the survey.
2.A sanitation audit was conducted of the kitchen area. Identified areas of concern where cleaned and sanitized.
3.Education regarding maintaining a clean and sanitaty kitchen provided to the Dietary Staff by the Dietary Manager and/or designee.
4.Kitchen sanitation audits will be completed weekly x 4 then monthly x 3 with results reviewed at the QAPI committee for determination of ongoing monitoring.

483.10(f)(10)(iii) REQUIREMENT Accounting and Records of Personal Funds:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(f)(10)(iii) Accounting and Records.
(A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf.
(B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident.
(C)The individual financial record must be available to the resident through quarterly statements and upon request.
Observations:

Based on resident and staff interviews, and review of facility documentation, it was determined that the facility failed to provide residents with their quarterly banking statements for three of five residents.

Findings include:

During a group interview on 5/14/25, at 10:45 a.m. residents indicated that they did not get quarterly statements from the facility for their monies that the facility receives. Residents indicated that they were not aware they were to receive quarterly statements for their monies.

During a review of residents quarterly statements the following was noted:

Resident R500: resident fund statement indicated that the responsible party of the resident received the resident fund quarterly statement for the period of 1/1/25, thru 3/31/25.

Resident R501: resident fund statement indicated that the responsible party of the resident received the resident fund quarterly statement for the period of 1/1/25, thru 3/31/25.

Resident R502: resident fund statement indicated that the responsible party of the resident received the resident fund quarterly statement for the period of 1/1/25, thru 3/31/25.

During an interview on 5/16/25, at 11:41 a.m. Business Office Manager Employee E12 confirmed that the facility sends out quarterly statement, and the person who receives the statement is indicated on the quarterly statement for the residents.

During an interview on 5/16/25, at 1:12 p.m. Nursing Home Administrator confirmed that the facility failed to send quarterly statements to residents who had monies in the resident account and sent to their responsible parties.

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

28 Pa. Code 201.29(a) Resident rights.





 Plan of Correction - To be completed: 07/02/2025

1. Alert and oriented residents that have a Resident Funds Account were provided with a Resident Funds statement at the time of survey.
2. An audit was conducted of residents with Resident Funds Accounts, who are alert and oriented, to assure their account is marked to provide the resident with a copy of their RFMS statement.
3. The NHA or designee will provide education to the BOM regarding resident's right to receive a copy of their RFMS statement quarterly. The BOM will provide education to the residents and families regarding the delivery of a quarterly resident funds account statement to alert and oriented residents. Education will be provided in person at the resident's counsel as well as in writing through the facility Care Feed notification system.
4. An audit shall be completed quarterly x 2 to assure that the alert and oriented residents with RFMS accounts, are provided with a quarterly statement of the account balance. Results will be shared with the QAPI committee.

483.10(e)(1), 483.12(a)(2), 483.45(c)(3)(d)(e) REQUIREMENT Right to be Free from Chemical Restraints:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(e) Respect and Dignity.
The resident has a right to be treated with respect and dignity, including:

§483.10(e)(1) The right to be free from any . . . chemical restraints
imposed for purposes of discipline or convenience, and not required to treat the
resident's medical symptoms, consistent with §483.12(a)(2).

§483.12
The resident has the right to be free from abuse, neglect, misappropriation of
resident property, and exploitation as defined in this subpart. This includes but is
not limited to freedom from corporal punishment, involuntary seclusion and any
physical or chemical restraint not required to treat the resident's medical
symptoms.
§483.12(a) The facility must-. . .
§483.12(a)(2) Ensure that the resident is free from . . . chemical restraints
imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.
. . . .
§483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories:
(i) Anti-psychotic;
(ii) Anti-depressant;
(iii) Anti-anxiety; and
(iv) Hypnotic.

§483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-
(1) In excessive dose (including duplicate drug therapy); or
(2) For excessive duration; or
(3) Without adequate monitoring; or
(4) Without adequate indications for its use; or
(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or
(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section.

§483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that--

§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record;

§483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

§483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and

§483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order.

§483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.
Observations:

Based on clinical record review, facility provided documents, and staff interview, it was determined that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for three of five residents (Residents R4, R86 and, R106).

Findings include:

Review of facility "Behavior Standard Index" dated 3/17/25, indicated the facility will develop and implement behavior plans and medication regimes, in efforts to optimize the functional abilities of residents while monitoring for adverse side effects and improve behaviors. When control is needed to prevent harm and to allow evaluation and treatment, psychotropic medication may be required. Behavioral sheets will be utilized at the time of drug initiation or admission to home with drug order. Behaviors must be quantitatively and objectively documented by the nursing staff. Non-pharmacological interventions are implemented and assessed for effectiveness prior to considering initiation of medication.

Review of the clinical record indicated Resident R4 was admitted to the facility on 3/8/2023.

Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/20/25, indicated diagnoses of anemia (low iron in the blood), hypertension (high blood pressure), and anxiety.

Review of Resident R4's physician order dated 2/21/25, indicated to administer Ativan oral tablet (a psychotropic medication used to treat anxiety) 0.5 milligram every eight hours as needed (PRN) for anxiety for six months.

Review of Resident R4's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R4's Ativan

Review of Resident R4's Medication Administration Record (MAR) dated February 2025 through May 2025, indicated that resident received Ativan PRN 24 times per order.

Review of Resident R4's Progress Notes dated February 2025 through May 2025 failed to indicate any documented non-pharmacological interventions used by staff prior to administering Resident R4's Ativan.

Review of the clinical record indicated Resident R86 was admitted to the facility on 3/3/2022.

Review of Resident R86's MDS dated 4/8/25, indicated diagnoses of high blood pressure, dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and anxiety.

Review of Resident R86's physician order revised on 5/15/25, indicated to administer Ativan Solution (a psychotropic medication used to treat anxiety), give 0.5 milliliters (ml) under tongue every four hours PRN for anxiety.

Review of Resident R86's physician order failed to include a 14 day stop date and there was no documented rationale by the physician for the medication to extend past 14 days for Resident R86's Ativan.

Review of Resident R86's Medication Administration Record dated January 2025 through May 2025, indicated that resident received Ativan PRN 11 times per order.

Review of Resident R86's Progress Notes dated January 2025 through May 2025 failed to indicate any documented non-pharmacological interventions used by staff prior to administering Resident R86's Ativan.

Resident R106 was admitted to the facility on 1/22/25.

Resident R106 MDS dated 3/10/25, indicated the following diagnosis Unspecified Nondisplaced Fracture Of Second Cervical Vertebra Subsequent Encounter For Fracture With Routine Healing ( a cervical fracture often called a broken neck) , wandering (person becomes lost or confused) and unspecified dementia ( a condition where people lose the ability to think, remember, learn, make decisions and solve problems).

Review of Resident R106's physican order dated 1/30/25:
Ativan Oral Tablet 0.5 MG
(Lorazepam)
Give 0.25 mg by mouth every 8
hours as needed for anxiety
-Start Date-
01/30/2025

Review of Resident R106's physician order failed to include a 14 days stop date and there was no documented rationale by the physician for the medication to extend past the 14 days for Resident R106's Ativan.

Review of Resident R106 MAR's January 2025 through March 2025 indicated that resident received Ativan 10 times.

Review of the progress notes dated January 2025 through March 2025 failed to indicate any documented non-pharmacological interventions used by staff prior to administering PRN Ativan.

During an interview on 5/16/25, at 11:04 a.m. Director of Nursing confirmed that the facility failed to ensure that residents medication regime was free from unnecessary psychotropic medication for three of five residents (Residents R4, R86 and, R106).

28 Pa. Code 211.2(d)(3) Medical director
28 Pa. Code 211.10(a) Resident care policies













 Plan of Correction - To be completed: 07/02/2025

1. R4, R86, R86 medication orders for prn Ativan will be reviewed by physician for necessity of continuation and a stop date will be added by 6/3/2025.
2. An audit will be completed by DON/designee for all residents that are receiving as needed antianxiety medications for stop dates. An audit DON/designee will also be conducted for documentation of non-pharmalogical interventions prior to use by 6/3/2025.
3. Physicians, CRNP, and nurses will be re-educated by DON/designee for any prn antianxiety medication 14 day stop date as well as documentation to continue thereafter and every 6 months. Nurses will also be re-educated by DON/designee for non-pharmalogical documentation prior to administration of prn antianxiety medications.
4. An audit will be completed by DON/designee for residents with new orders/reorder antianxiety for stop date as well as physician documentation for continuation when indicated. An audit will be conducted by DON/designee for documentation of nonpharmalogical interventions prior to use of prn antianxiety 3 x a week x 2 weeks then weekly x 2. Results of the audits will be brought to the QAPI meeting for review.

483.10(j)(1)-(4) REQUIREMENT Grievances: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(j) Grievances.
§483.10(j)(1) The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay.

§483.10(j)(2) The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.

§483.10(j)(3) The facility must make information on how to file a grievance or complaint available to the resident.

§483.10(j)(4) The facility must establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights contained in this paragraph. Upon request, the provider must give a copy of the grievance policy to the resident. The grievance policy must include:
(i) Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number; a reasonable expected time frame for completing the review of the grievance; the right to obtain a written decision regarding his or her grievance; and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system;
(ii) Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;
(iii) As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;
(iv) Consistent with §483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider; and as required by State law;
(v) Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;
(vi) Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility; and
(vii) Maintaining evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision.
Observations:

Based on review of facility policy, and resident and staff interview , it was determined that the facility failed to inform residents on the grievance policy and procedures for seven of seven residents.

Findings include:

Review of facility policy "Communication of Resident, Family, and Staff Concerns and Grievances", stated 3/17/25, indicated: " The facility offers several communication avenues for residents, family members, and staff to questions and to report any concerns related to quality of care, customer service, regulatory issue or employee matter".

Resident group interview on 5/14/25, at 10:40 a.m. indicated that residents did not know who the grievance officer was, how to file a grievance, where the grievance forms were or what the process was. Residents were asked how the facility responds to grievances and the residents said that they did not know how they respond to concerns.

Review of resident council minutes for six months (November, December, January, Febraury, March, and April) failed to include discussion of resident rights, how residents file grievance, where the grievances were located, who the grievance officer was, or any information about resident rights or grievances.

During an interview on 5/16/25, at 10:04 a.m. Social Worker Employee E5 confirmed that they are the grievance officer and they attend resident council.

During a subsequent interview on 5/16/25, at 10:58 a.m. Social Worker Employee E5 confirmed that no information could be found to support that the facility had informed residents of the grievance process, and that the facility failed to inform residents on the grievance process policy and procedures.

28 Pa. Code 201.29(a)Resident rights








 Plan of Correction - To be completed: 07/02/2025

1. Residents noted were not identified.
2. Residents and Families were notified by way of the facility Care Feed Notification system and at the resident counsel meeting of Resident's Right's and the process to follow to file a grievance verbally or in writing as well as the name of the grievance officer with contact information.
3. The topic of Resident Rights and Grievances has been added to the routine agenda items for the resident council meetings. Minutes of each council meeting are posted on the bulletin board at wheelchair height. Minutes are also distributed to those that attend the meeting.
4. Quality audits will be completed monthly x 2 to assure the grievances and resident rights are addressed within resident council.

483.90(d)(2) REQUIREMENT Essential Equipment, Safe Operating Condition: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.
§483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.
Observations:

Based on observations, review of facility documentation, and staff interview, it was determined that the facility failed to make certain that equipment was in safe operating condition for one of three crash carts (Exam Room).

Findings include:

Review of the facility "Emergency Cart" policy dated 3/17/25, indicated the emergency cart will be appropriately stocked and ready for use when attempting to resuscitate a resident. The cart will be readily available for use and its inventory maintained.

During an observation of the Exam Room crash cart (a cart maintained with equipment used in cardiac emergencies) on 5/14/25, at 10:49 a.m. revealed the following expired supplies:

- Foley Insertion Kit (a thin flexible tube inserted into the bladder to drain urine), expired 1/31/25.
- IV Start Kit expired 10/31/24.
- Syringe Piston not sealed closed.
- Dressing Kit expired 3/2/25.
- Yanker Suction device (used to clear drainage out of a person ' s mouth) expired 11/28/24.
- Tracheostomy (an opening in the front of the neck that provides an airway for breathing) Care Tray expired 6/1/24.

During an interview on 5/14/25, at 10:45 a.m. Assistant Director of Nursing Employee E3 confirmed the above observations and confirmed that the facility failed to make certain that equipment was in safe operating condition for one of three crash carts, as required.

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





 Plan of Correction - To be completed: 07/02/2025

1. The expired foley insertion kit, expired IV start kit, unsealed piston syringe, expired dressing kit, expired yanker and tracheostomy kit were removed from the emergency cart and destroyed. The DON replaced items with new items at the time of survey.
2. An audit was completed of the all emergency carts for any other expired or unsealed items on 5/14/2025.
3. The RN's will be re-educated on the emergency cart policy in regards to monthly check for appropriately stocking / inspection for expired items by the DON/designee.
4. An audit will be completed of all emergency cart stocked items for expiration dates and completed inspections by DON/designee weekly x 4 weeks. Results of the audits will be brought to the QAPI meeting for review

483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control: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.
§483.80 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 facility policy, clinical record review, observation, and staff interview, it was determined that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R107).

Findings include:

Review of the facility policy "Skin Integrity and Wound Management" last reviewed 3/17/25, indicates to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment and promote healing of all wounds.

Review of the facility policy "Wound Dressing Change" last reviewed 3/17/25, indicates all wound care will be performed using medical aseptic technique, unless otherwise ordered by the physician, to prevent contamination of the wound bed. Procedure includes but not inclusive to:
If a break in the aseptic technique occurs at any point, stop the procedure, remove your gloves, cleanse your hands, re-glove and/or re-gown and continue the procedure.
Individual resident supplies may be placed on the over-bed table after it has been disinfected and a protective barrier has been placed on the table.

Review of Resident R107's clinical record indicated he was admitted to the facility on 2/22/25.

Review of Residents R107's physician orders dated 5/7/25, indicate to cleanse right lateral unstageable wound with soap and warm water, pat dry, skin prep peri wound, apply nickel thick Santyl ointment, cover with dry dressing every day shift .

During an observation on 5/24/25, at 1:34 p.m. Licensed Practical Nurse (LPN) Employee E11 entered Resident R107's room to complete his dressing change. LPN Employee E11 placed a towel on Resident R107's bed and placed the dressing supplies on the towel. She removed Resident R107's boot and sock and placed on chair, removed her gloves and placed new gloves. After applying the Santyl ointment she removed her gloves and removed a pen from her pocket and applied the date to the cover dressing, she returned the pen to her pocket and applied new gloves.

During an interview on 05/24/25, at 1:57 p.m. LPN Employee E11 confirmed the failure to set up a clean barrier field, not completing hand hygiene after removal of gloves, and that the facility failed to prevent cross contamination during a dressing change for one of three residents (Resident R107).


28 Pa. Code: 211.10(d) Resident Care Policies.
28 Pa. Code: 211.12(d)(1)(5) Nursing Services.


 Plan of Correction - To be completed: 07/02/2025

1. E11 will be re-educated on wound dressing change policy and have a clean dressing competency completed by DON/designee on 5/28/25.
2. Nurses will be re-educated by DON/designee on wound dressing change policy. Clean dressing change competencies will be completed by DON/designee.
3. Audits will be completed by DON/designee on the nurses technique for clean dressing changes, random nurses, 3 x a week x 2 weeks then weekly x 2 weeks based on residents with orders.
4. Results of the audits will be brought to the QAPI meeting for review

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals: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.
§483.45(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 facility policies, observations, and staff interviews, it was determined that the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms (Hemlock Medication Room), and failed to store medications and biologicals properly and securely in three of five medications carts (Hickory hall, Hemlock hall, and Willow hall medication carts).

Findings include:

Review of the facility policy "Storage of Medications" last reviewed 3/17/25, indicates medications and biologicals are stored safely, securely, and properly, following manufacture's recommendations or those of the supplier. Orally administered medications are kept separate from externally used medications and treatments. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory. The nurse will check the expiration date of each medication before administering it.

Review of the facility policy "Administration Procedures for all Medications" last reviewed 3/17/25, indicated to administer medications in a safe effective manner. Check expiration date on package/container before administering any medication. When opening a multidose container, place the date on the container.

During an observation on 5/13/25, at 11:25 a.m. the Hemlock medication room contained the following:

1. Two vials of Tuberculin (a substance used to detect a respiratory condition) that were expired.

During an interview on 5/13/25, at 11:29 a.m. Licensed Practical Nurse (LPN) confirmed the above findings.

During an observation on 5/13/25, at 1:51 p.m. the Hickory hall medication cart contained the following:

1. One medication cup of prepoured pills containing one white pill.
2. One medication cup of prepoured pills containing one black pill, two blue pills, two white and pink pills, two white pills, two peach pills, two orange pills, and one yellow pill.
3. One medication cup of prepoured pills containing nine white pills, two orange pills, one red pill, one blue pill, and one peach pill.
4. One cup of prepoured liquid containing a powdered medication.

During an inteview on 5/13/25, at 2:05 p.m. LPN Employee E2 stated that they were three different resident's medications who were not in their room, and was waiting for them to return to their rooms.

During an interview on 5/13/25, at 2:08 p.m. LPN Employee E2 confirmed the above findings.

During an observation on 5/13/25, at 2:20 p.m. the Hemlock hall medication cart contained the following:

1. Lantus Insulin Pen (a medication used to treat diabetes-a metabolic disorder in which the body has high sugar levels for prolonged periods of time) with no open or expiration date.

During an interview on 5/13/25, at 2:22 p.m. LPN Employee E1 confirmed the above findings.

During an observation on 5/14/25, at 9:35 a.m. the Willow hall medication cart contained the following:

1. Bisacodyl suppositories comingling with oral medications.
2. Tioujeo insulin pen unlabeled, not dated and not stored in a bag.
3. Two bottles of lactulose liquid opened and without a date.
4. A bottle of sore throat spray opened and without a date
5. A bottle fluticasone nose spray opened and without a date

During an interview completed on 5/14/25, at 9:45 a.m. LPN Employee E11 confirmed the above findings.

During an inteview on 5/14/25, at 3:00 p.m. the Director of Nursing confirmed the facility failed to store all drugs and biologicals in a safe, secure, and orderly manner for one of two medication rooms, and failed to store medications and biologicals properly and securely in three of five medications carts.


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






 Plan of Correction - To be completed: 07/02/2025

1. The 2 TB vials were removed and destroyed at facility. The 3 medication cups of prepoured pills and prepoured liquids were destroyed. Nurse prepared the medication and administered individually according to the MD orders. Nurse re-educated about 5 rights of medication pass and a competency will be completed by 5/31/2025 by DON/designee. The lantus pen, tiougeo insulin pen, lactulose, sore throat spray, fluticasone, bisacodyl suppositories were removed, then destroyed by facility nurse. Medications were re-ordered from pharmacy.
2. An audit will be completed by DON/designee for other medication pre-poured in the medication carts, opened bottles without a date, undated insulin, and TB serum by 6/2/2025.
3. Nurses will be re-educated by DON/designee according of storage of medication policy, including the dating of multi-dose/use vials and medication administration competency by DON/designee.
4. Audits will be completed of all the medication carts for pre-poured medications, opened bottles without a date, opened insulin without a date, and TB serum without a date 3 x a week x 2 weeks then weekly x 2. Results of the audits will be brought to the QAPI meeting for review

483.45(f)(2) REQUIREMENT Residents are Free of Significant Med Errors:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
The facility must ensure that its-
§483.45(f)(2) Residents are free of any significant medication errors.
Observations:

Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to make certain medications were administered as ordered by the physician for one of three residents (Resident R88).

Findings include:

Review of the facility policy "Specific Medication Administration Procedures" last reviewed 3/17/25, indicates to administer medications in a safe and effective manner. After administration, return to cart, replace medication container (if multi-dose and doses remain).

Review of the facility policy " Physician Orders" last reviewed 3/17/25, last reviewed 3/17/25. indicated physician orders are followed in accordance with good nursing principles and practices and are transcribed and carried out by persons legally authorized to do so.

Review of Resident R88's clinical record indicated she was admitted to the facility on 4/8/22.

Review of Resident R88's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/2/25, indicated diagnosis of anemia (low iron in the blood), heart failure (the heart doesn't pump the way it should) and hypertension (high blood pressure)

Review of a physician order dated 8/13/24, indicated to administer artificial tear solution one drop in both eyes two times a day.

During a medication pass observation completed on 5/13/25, at 9:44 a.m. Licensed Practical Nurse (LPN) Employee E2 was preparing medications for Resident R88, LPN Employee E2 removed a box of artificial tears from the medication cart and placed into her scrub top pocket. LPN Employee E2 administered Resident R88's medication, however the eye drops were not given. LPN Employee E2 returned to medication cart and began preparing medication for the next resident. Upon asking about the eye drops LPN Employee E2 removed the eye drops from her pocket.

During an interview completed on 5/13/25, at 10:52 a.m. LPN Employee E2 confirmed she did not administer Resident R88's eye drops as ordered and that the facility failed to make certain medications were administered as ordered by the physician

28 Pa. Code 211.12 (c)(1)(3) Nursing Services.









 Plan of Correction - To be completed: 07/02/2025

1. When E2 was notified on 5/13/2025 R88 eye drops were administered as ordered.
2. Nurses will be re-educated and complete a medication pass competency completed DON/designee for specific medication administration procedures and physician orders to administer all medications.
3. Nurses will receive a medication pass audit will be completed by DON/designee 3 x a week x 2 weeks then weekly x 2 weeks.
4. Results of the audits will be brought to the QAPI meeting for review

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 review of resident record review, and staff interviews, it was determined that the facility failed to provide a trauma survivor with trauma informed care to eliminate or mitigate triggers that may cause re-traumatization of the resident for two of two residents (Resident R4, and R9).

Findings include:

Review of the clinical record indicated Resident R4 was admitted to the facility on 3/8/23.

Review of Resident R4's MDS (Minimum Data Set - a periodic mandatory Federal assessment used to determine a resident's care needs) dated 2/20/25, indicated diagnoses of post-traumatic stress disorder (PTSD-a mental health condition in people who have experienced or witnessed a traumatic event), anemia (low iron in the blood) and high blood pressure.

Review of Resident R4's care plan indicated that resident had PTSD but failed to identify what the triggers were and how to avoid them.

Review of the clinical record indicated Resident R9 was admitted to the facility on 9/19/24.

Review of Resident R9's MDS dated 3/18/25, indicated diagnoses of PTSD, coronary artery disease (damage or disease in the heart's major blood vessels), and dementia (a group of symptoms that affects memory, thinking and interferes with daily life).

Review of Resident R9's care plan indicated that resident had PTSD but failed to identify what the triggers were and how to avoid them.

During an interview on 5/16/25, at 10:17 a.m. Social Service Director Employee E5 confirmed that the facility failed to identify PTSD triggers for Resident R4, and R9 in order to eliminate or mitigate any triggers that may cause re-traumatization for the resident.

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18(b)(1) Management.













 Plan of Correction - To be completed: 07/02/2025

1. Resident R4 and R9 care plans have been updated to include triggers that may cause re-traumatization.
2. Look back of current resident population that has indicated a history of PTSD have been reviewed with plan of care updated to include triggers that may cause re-traumatization.
3. NHA provided education to Social Services regarding updating the plan of care to include the specifically identified triggers that may cause re-traumatization to the resident.
4. NHA or designee will conduct Quality audit of new PTDS diagnosis care plans to assure specific triggers are noted within the plan of care shall be conducted 3 x a week x 2 weeks then weekly x 2 weeks. Results shall be shared at the QAPI committee for further recommendations.

483.25(h) REQUIREMENT Parenteral/IV Fluids: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(h) Parenteral Fluids.
Parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences.
Observations:

Based on review of facility policy, observations, and staff interviews, it was determined that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R70).

Findings include:

Review of the facility provided quick reference guide last reviewed 3/17/25, indicates dressing changes to central lines: PICC should be performed every seven days and if needed as soiled using aseptic (practices to prevent infection) technique.

Review of the clinical record indicated Resident R70 was admitted to the facility on 4/14/25.

Review of Resident R70's Minimum Data Set (MDS - a periodic assessment of care needs) dated 4/15/25, indicated diagnoses of heart failure (a progressive heart disease that affects pumping action of the heart muscles), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and osteomyelitis (infection of bone) of the right ankle and foot.

Review of physician orders dated 4/14/24, indicated Zosyn Solution Reconstituted 3- 0.375 gram (GM) Use 1 vial intravenously (IV) every eight hours.

Review of Resident R70's care plan dated 4/15/25, focus indicates PICC line therapy related to infection. Intervention/task indicates check my IV site for any signs or symptoms of infection, such as redness, warmth or swelling and notify my physician if any are noted. Ensure that my dressing remains intact and is changed according to the protocol in my home or as otherwise ordered.

During an observation on 5/13/25, at 9:35 a.m. Resident R70's left arm PICC site dressing was labeled with the date of 4/29/25.

During an interview completed on 5/13/25, at 9:40 a.m. Licensed Practical Nurse (LPN) Employee E2 confirmed the dressing site was dated 4/29/25, and that the facility failed to provide adequate treatment and care for a peripheral inserted central catheter (PICC - a thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart) in accordance with professional standards of practice for one of two residents (Resident R70).

28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing Services.
28 Pa. Code: 201.14(a) Responsibility of licensee.







 Plan of Correction - To be completed: 07/02/2025

1. R70's PICC line dressing was removed on 5/13/2025. R70 moved arm during IV dressing change which cause line to be partially removed. IV line was pulled. MD notified and order obtained to insert IV midline. IV midline inserted as per order. New order for dressing change q 7 days
2. An audit was completed by DON for other residents with MD orders for IV dressings due to be changed every 7 days on 5/13/2025.
3. Nurses will be re-educated by DON/designee regarding central lines dressings every 7 days and as needed according to the quick reference guide for IV's.
4. An audit will be completed by DON/designee for residents with IV dressings due to be changed every 7 days 2 x a week and then weekly x 2 weeks. Results of the audits will be brought to the QAPI meeting for review

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:

Based on review of facility policy, clinical record review, and staff interview it was determined that the facility failed to provide adequate supervision to prevent elopement for one of three residents (Resident R106).

Findings include:

Review of the facility policy "Accidents and Incidents" dated 3/17/25, indicated: "An accident/incident is any happening, which is not consistent with routine operations or the routine care of the particular resident".

Resident R106 was admitted to the facility on 1/22/25.

Resident R106's MDS (minimum data set an assessment of resident needs) dated 3/10/25, indicated the following diagnosis Unspecified Nondisplaced Fracture Of Second Cervical Vertebra Subsequent Encounter For Fracture With Routine Healing ( a cervical fracture often called a broken neck) , wandering (person becomes lost or confused), and unspecified dementia ( a condition where people lose the ability to think, remember, learn, make decisions and solve problems).

Review of facility documentation progress notes dated 3/13/25, indicated the following:

Staff came to unit at approximately 4:40 pm, to notify nursing staff that resident was in the kitchen area. Employee E14 Nurse Aide went down to the kitchen and redirected Resident R106 back to the unit. Resident R106 has been wandering throughout the building this entire shift. Resident R106 requires continuous redirection to stay out of other residents' rooms.

Review of Resident R106's clinical record failed to include a care plan for wandering.

During an interview on 5/13/25, Employee E14 Nurse Aide indicated that staff from the kitchen came to the unit and said there was a resident in the kitchen who needed taken back to the nursing unit. Upon arrival to the area Resident R106 was in the area (a storage room) before the kitchen. I took Resident R106 back to the nursing unit. Resident R106 indicated that they were looking for a cup of coffee, I gave the Resident a cup of coffee once back on the nursing unit.

During an interview on 5/14/25, Director of Nursing (DON) confirmed that Resident R106 has a history of wandering, did go into an area that was not designated for residents, that the resident was originally identified in the area by a dietary aide who in turn went to the nursing unit to get a nursing staff to bring resident back to the nursing unit.

During an inteview on 5/14/25, at 2:30 p.m. DON was informed that the facility failed to provide adequate supervision to prevent elopement for one of three residents (Resident R106).

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: 07/02/2025

1. R106 was assed fpr proper level of supervision with the care plan updated on 5/14/2025.
2. A house audit was completed on 5/14/2025 for the identification of residents at risk for elopement by RNAC/LPNAC and social service.
3. Nurses, RNAC, LPNAC, and social service will be re-educated by DON/designee for accident prevention, including adequate supervision for accident prevention.
4. An audit will be completed by DON/designee of resident incidents to ascertain if proper supervision was provided and care planned. 2 x a week x 2 weeks than weekly x 2 weeks. Results of the audits will be brought to the QAPI meeting for review

483.25 REQUIREMENT Quality of 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 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 a review of facility policy, clinical record, and staff interview, it was determined that the facility failed to provide an ongoing neurological assessment post unwitnessed fall for one of four residents (Resident R100).

Findings include:

Review of the facility policy "Falls: Care During and After" last reviewed 3/17/25, indicates all residents experiencing a fall will receive appropriate care and investigation of the cause. Assess residents ' condition immediately to determine extent of injury for both witnesses and unwitnessed falls by following "Guideline for Fall Aftercare".
Guidelines for Fall Aftercare:
- If head injury, assess neurological status.
- Monitor resident, including vital signs and neurological checks as indicated and ordered.

Review of the clinical record indicated that Resident R100 was admitted to the facility on 4/16/24.

Review of Resident R100's Minimum Data Set (MDS - a periodic assessment of care needs) dated 3/11/25, indicated diagnoses of unsteadiness on feet, abnormalities of gait and mobility, and hypertension (high blood pressure). Section C-cognitive patterns brief interview for mental status (BIMS-a tool to evaluate orientation and recall in residents) 0-7 points indicates severely impaired cognition, 8-12 indicates moderate impaired cognition and 13-15 indicates intact cognition. Resident R100's score C0400 is marked as 03, indicating severe impairment.

Review of Resident R100's care plan initiated on 4/24/24, indicates at risk for falls.

Review of Resident R100's fall with injury statement dated 12/25/24, indicates writer was assisting another resident when heard a thud. Upon investigation found resident laying on his side on the floor. He said he did not hit his head but did hit his arm off the nightstand and had four separate skin tears. The physician and resident's son were notified.

Review of Resident R100's physician orders and treatment administration record (TAR) for December 2025, failed to include post fall neurological checks for the unwitnessed fall.

During an interview on 5/16/25, at 10:43 a.m. the Director of Nursing (DON) confirmed the facility failed to provide an ongoing neurological assessment post unwitnessed fall for one of four residents (Resident R100).

28 Pa. Code: 201.14(a) Responsibility of licensee.
28 Pa. Code: 201.18 (b)(1) Management.
28 Pa. Code: 211.10 (c)(d) Resident Care policies.
28 Pa. Code: 211.12 (d)(1)(2)(3)(5) Nursing services.












 Plan of Correction - To be completed: 07/02/2025

1. R100 did not have neuro checks completed after an un-witness fall on 12/25/2024.
2. Nurses will be educated by DON/designee on policy for falls care during and after. If a head injury, neurological status checks and vital signs.
3. An audit will be completed by DON/designee for residents after fall care: neuro checks and vital signs 3 x a week x 2 weeks then weekly x 2 weeks .
4. Results of the audits will be brought to the QAPI meeting for review

483.15(c)(1)(2)(i)(ii)(7)(e)(1)(2);483.21(c)(1)(2)(iv) REQUIREMENT Inappropriate Discharge: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.
§483.15(c) Transfer and discharge-
§483.15(c)(1) Facility requirements-
§483.15(c)(1)(i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless-
(A)The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility;
(B)The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility;
(C)The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident;
(D)The health of individuals in the facility would otherwise be endangered;
(E)The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or
(F)The facility ceases to operate.

§483.15(c)(1)(ii) The facility may not transfer or discharge the resident while the appeal is pending, pursuant to § 431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to § 431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose.

§483.15(c)(2) Documentation.
When the facility transfers or discharges a resident under any of the circumstances specified in paragraphs (c)(1)(i)(A) through (F) of this section, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider.
(i)Documentation in the resident's medical record must include:
(A) The basis for the transfer per paragraph (c)(1)(i) of this section.
(B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s).
(ii)The documentation required by paragraph (c)(2)(i) of this section must be made by-
(A) The resident's physician when transfer or discharge is necessary under paragraph (c) (1) (A) or (B) of this section; and
(B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section.

§483.15(c)(7) Orientation for transfer or discharge.
A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand.

§483.15(e)(1) Permitting residents to return to facility.
A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following.
(i)A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semi-private room if the resident-
(A) Requires the services provided by the facility; and
(B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services
(ii)If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges.

§483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there.

§483.21(c)(1) Discharge Planning Process
The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and-
(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident.
(ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes.
(iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan.
(iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs.
(v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan.
(vi) Address the resident's goals of care and treatment preferences.
(vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community.
(A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose.
(B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities.
(C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why.
(viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a post-acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences.
(ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer.

§483.21(c)(2) Discharge Summary
When the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, the following:

(iv) A post-discharge plan of care that is developed with the participation of the resident and, with the resident's consent, the resident representative(s), which will assist the resident to adjust to his or her new living environment. The post-discharge plan of care must indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post-discharge medical and non-medical services.
Observations:

Based on review of facility policy, clinical record review, and staff interview, it was determined that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Resident R57) and failed to provide a discharge summary completed by a physician for one of two residents (Resident R108).

Findings include:

Review of facility policy "Transfer of Resident to Another Care Community" dated 3/17/25, indicated transfer of resident to another care community is carried out based on physician order. Copy and prepare documents needed for transfer, including, but not limited to:
- Medical Records Face sheet
- Advanced Directives/POLST
- Current physician orders
- Medication Administration Record
- Problem List
- History and Physical
- Appointments
- Lab Work

Review of the clinical record indicated Resident R57 was admitted to the facility on 11/23/20.

Review of Resident R57's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/8/25, indicated diagnoses of anemia (too little iron in the body causing fatigue), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time)

Review of the clinical record indicated Resident R57 was transferred to the hospital on 10/8/25 and returned to the facility on 10/17/25.

Review of Resident R57's clinical record revealed no documented evidence that the facility had communicated specific information to the receiving health care provider for the residents transferred and expected to return, which included the resident's care plan goals, advanced directive information, specific instructions for ongoing care, resident representative information, and all information necessary to meet the resident's specific needs at the receiving facility.

Review of the clinical record indicated Resident R108 was admitted to the facility on 1/9/25.

Review of Resident R108's MDS dated 2/12/25, indicated diagnoses of chest pain, vitamin deficiency, and osteoporosis (condition when the bones become brittle and fragile).

Review of clinical record indicated Resident R108 left the facility Against Medical Advice (AMA) on 2/12/25.

During a closed record review on 5/15/25, at 1:10 p.m. the facility failed to provide a discharge summary completed by the physician after Resident R108 left the facility.

During an interview on 5/15/25, at 1:23 p.m. Medical Records Employee E4 confirmed that the discharge summary was not included in Resident R108's medical record.

During an interview on 5/16/25, at 10:54 a.m. Director of Nursing confirmed that the facility failed to make certain that the necessary resident information was communicated to the receiving health care provider for one of three residents sampled with facility-initiated transfers (Resident R57) and failed to provide a discharge summary from a physician for one of two residents (Resident R108).

28 Pa. Code 201.29 (a) (c.3) (2) Resident rights.






 Plan of Correction - To be completed: 07/02/2025

1. R108 discharge summary completed by physician 6/5/2025.
2. An audit will be completed by DON/designee for resident that have been discharged in past 30 days to ensure a physician discharge summary was completed by 6/5/2025. Charts out of compliance will have a physician discharge summary completed on next physician visit into facility.
3. Physicians / CRNP will be re-educated by DON/designee that a residents discharge summary needs to be completed within 30 days of discharge. Nurses will be re-educated by DON/designee for necessary resident information to be provided to transferring health care facility to include the following: residents care plan, bed hold policy, POLST, medication record, face sheet, and transfer summary.
4. An audit will be completed by DON/designee for physician discharge summaries within 30 days of discharge 3 x a week x 2 weeks than weekly x 2 weeks.
An audit will be completed for residents that have been transferred to a health care facility for a transfer discharge summary and documents sent upon transfer. 3 x a week x 2 weeks than weekly x 2 weeks. Results of the audits will be brought to the QAPI meeting for review

483.12(c)(2)-(4) REQUIREMENT Investigate/Prevent/Correct Alleged Violation: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.
§483.12(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 review of facility policy, clinical record review and staff interview, it was determined that the facility failed to fully investigate an incident to eliminate possible abuse neglect for one of four residents (Resident R260).

Findings include:

The facility's policy "Resident Protection from Abuse, Neglect, Mistreatment or exploitation" last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action.

- Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
- Neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish, or emotional distress.
- Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress.
Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to:
- reports from employed or contracted staff.
- utilization of resident incident reports to determine suspicious events.
Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected:
- The Administrator (NHA) or Director of Nursing (DON) must be notified immediately.
- The NHA or DON will notify the Pennsylvania department of health.
Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented.
- An internal investigation will be conducted utilizing the resident incident report, the PB-22 form, interviews of resident, staff, and family members and description of the resident's injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as possible.

Review of admission record indicated Resident R260 was admitted to the facility on 10/1/24.

Review of Resident R260's MDS dated 10/4/24, indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression.: Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns).

Review of Resident R260's physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor, safety devices bed and chair alarms, low bed to floor.

Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance. Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed.

Review of the facility provided incident reported dated 10/15/24, indicated NA entered resident 260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident ' s alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility.

Review of Resident R260's mobile x- ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x- ray completed: impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow.

Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x-ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow.

Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider.

Review of Resident R260's progress notes indicated a follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture.

Review of facility submitted reports did not include the allegation of neglect or that an investigation was completed.

During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that the facility failed to fully investigate an incident to eliminate possible neglect for one of four residents (R260).

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.







 Plan of Correction - To be completed: 07/02/2025

1. R260 ERS submitted to DOH on 5/15/2025, complete investigation conducted - PB22 submitted and accepted on 5/20/25.
2. An audit of the past 180 days will be conducted by NHA of incidents/accidents to ensure incidents/accidents have been internally investigated utilizing the incident report, PB-22 form, interviews of resident, staff, and family with a description of resident injuries. All investigations will be conducted thoroughly and attempt to gather as much factual information as possible by 6/15/2025
3. DON/ADON and licensed nursing staff will be re-educated by NHA for Resident protection from abuse, neglect, mistreatment or exploitation policy. Internal investigated utilizing the incident report, PB-22 form, interviews of resident, staff, and family with a description of resident injuries. All investigations will be conducted thoroughly and attempt to gather as much factual information.
4. An audit will be completed by NHA for incidents/accidents investigation are completed thoroughly investigated and when indicated reported to DOH when indicated. 3 x a week x 2 weeks then weekly x 2 weeks. Results of the audits will be brought to the QAPI meeting for review

483.12(b)(5)(i)(A)(B)(c)(1)(4) REQUIREMENT Reporting of Alleged Violations: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.
§483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must:

§483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

§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 review of facility policy, resident clinical record, incident reports, reports submitted to the State, and staff interview it was determined that the facility failed to report an allegation of neglect for one of three residents (Resident R260).

Findings include:

The facility's policy "Resident Protection from Abuse, Neglect, Mistreatment or exploitation" last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action.
- Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
- Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish, or emotional distress.
- Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress.
Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to:
- reports from employed or contracted staff.
- utilization of resident incident reports to determine suspicious events.
Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected:
- The Administrator (NHA) or Director of Nursing (DON) must be notified immediately.
- The NHA or DON will notify the Pennsylvania department of health.
Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented.
- An internal investigation will be conducted utilizing the resident incident report, the PB-22 form, interviews of resident, staff, and family members and description of the resident ' s injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as possible.

Review of admission record indicated Resident R260 was admitted to the facility on 10/1/24.

Review of Resident R260's MDS dated 10/4/24, indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression.: Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns).

Review of Resident R260's physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor,safety devices bed and chair alarms, low bed to floor.

Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance. Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed.

Review of the facility provided incident reported dated 10/15/24, indicated NA entered resident 260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident ' s alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents ' room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility.

Review of Resident R260's mobile x-ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x-ray completed: impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow.

Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x-ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow.

Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider.

Review of Resident R260's progress notes indicated a follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture.

Review of facility submitted events to the state survey agency failed to include the report of an allegation of neglect.

During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that that the facility failed to report an allegation of neglect for one of three residents (Resident R260).

28 Pa Code: 201.14 (a)(c )(e ) Responsibility of management
28 Pa Code: 201.18 (b)(1) (e)(1) Management.










 Plan of Correction - To be completed: 07/02/2025

1. R260 ERS submitted to DOH on 5/15/2025
2. An audit will be conducted by NHA of incidents/accidents over past 30 days for possible neglect that have not been reported to DOH by 6/15/2025
3. DON/ADON will be re-educated by NHA for Resident protection from abuse, neglect, mistreatment or exploitation policy.
4. An audit will be completed by NHA for incidents/accidents to ensure any allegation of neglect is submitted to DOH 3 x a week x 2 weeks then weekly x 2 weeks. Results of the audits will be brought to the QAPI meeting for review

483.12(b)(1)-(5)(ii)(iii) REQUIREMENT Develop/Implement Abuse/Neglect Policies: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.
§483.12(b) The facility must develop and implement written policies and procedures that:

§483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property,

§483.12(b)(2) Establish policies and procedures to investigate any such allegations, and

§483.12(b)(3) Include training as required at paragraph §483.95,

§483.12(b)(4) Establish coordination with the QAPI program required under §483.75.

§483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements.

§483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act.

§483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.
Observations:

Based on review of facility documents, facility policy, clinical records, and staff interviews, it was determined that the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation with a complete and thorough investigation of an incident involving the potential for neglect for one of four residents (Resident R260).

Findings include:

The facility's policy "Resident Protection from Abuse, Neglect, Mistreatment or exploitation" last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action.

- Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
- Neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish , or emotional distress.
- Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress.
Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to:
- reports from employed or contracted staff.
- utilization of resident incident reports to determine suspicious events.
Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected:
- The Administrator (NHA) or Director of Nursing (DON) must be notified immediately.
- The NHA or DON will notify the Pennsylvania department of health.
Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented.
- An internal investigation will be conducted utilizing the resident incident report, the PB-22 form, interviews of resident, staff, and family members and description of the resident's injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as possible.

Review of admission record indicated Resident R260 was admitted to the facility on 10/1/24.

Review of Resident R260's MDS dated 10/4/24, indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression. : Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns).

Review of Resident R260's physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor, safety devices bed and chair alarms, low bed to floor.

Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance.
Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed.

Review of the facility provided incident reported dated 10/15/24, indicated NA entered resident 260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident ' s alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility.

Review of Resident R260's mobile x- ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x ray completed impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow.

Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x -ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow.

Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider.

Review of Resident R260's progress notes indicated follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture.

During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that resident R260 was an assist of two for transfers, a high fall risk, and that Resident R260 was left in the bathroom unattended resulting in a fall that caused a dislocation of right elbow, fracture of the distal radius and a fractured of the coronoid process of the ulna and confirmed that the facility failed to implement written policies and procedures to ensure a complete and thorough investigation of an incident involving the potential for neglect for one of four residents (Resident R260).

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(e)(1) Management.











 Plan of Correction - To be completed: 07/02/2025

1. R260 ERS submitted to DOH on 5/15/2025
2. An audit will be conducted by NHA of incidents/accidents over past 30 days for possible neglect that have not been reported to DOH by 6/15/2025
3. DON/ADON will be re-educated by NHA for Resident protection from abuse, neglect, mistreatment or exploitation policy. DON or designee all staff will be provided education regarding Resident protection from abuse, neglect, mistreatment or exploitation policy.
4. An audit will be completed by NHA for incidents/accidents to ensure any allegation of neglect is submitted to DOH 3 x a week x 2 weeks then weekly x 2 weeks. Results of the audits will be brought to the QAPI meeting for review

483.12(a)(1) REQUIREMENT Free from Abuse and Neglect: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.
§483.12 Freedom from Abuse, Neglect, and Exploitation
The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms.

§483.12(a) The facility must-

§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;
Observations:

Based on review of facility policies, facility provided documents, clinical records and staff interviews, it was determined that the facility failed to make certain a resident was free from neglect for two of five residents reviewed (Resident R48 and R260) which resulted in actual harm of a skin tear (Resident R48) and a dislocation of right elbow, fracture of the right distal radius (bone near wrist) and a fractured of the right coronoid process of the ulna (bone of forearm) (Resident R260).

Findings include:

The facility's policy "Resident Protection from Abuse, Neglect, Mistreatment or exploitation" last reviewed 3/17/25, indicated it is the facility's policy to treat residents with kindness, respect and in a manner that is at all times free from abuse, neglect, misappropriation of property, exploitation or mistreatment. To protect our residents, procedures will be implemented in the areas of screening, training, prevention, identification, investigation, protection, reporting/response and corrective action.

- Neglect is defined of the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.
- Neglect occurs when the facility is aware of or should have been aware of goods or services that a resident requires but the facility fails to provide them to a resident, that has resulted or may result in physical harm, pain, mental anguish, or emotional distress.
- Neglect includes cases where the facilities indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in physical harm, pain, mental anguish or emotional distress.
Identification: Abuse, neglect, misappropriation of property and exploitation will be identified through various methods that include but not inclusive to:
- reports from employed or contracted staff.
- utilization of resident incident reports to determine suspicious events.
Reporting/Response - the following procedure will be implemented when an incident of abuse, neglect, exploitation, or mistreatment including injuries of unknow source alleged or suspected:
- The Administrator (NHA) or Director of Nursing (DON) must be notified immediately.
- The NHA or DON will notify the Pennsylvania department of health.
Investigation - all reports of abuse, neglect, exploitation or mistreatment including injuries of unknown source will be investigated and documented.
- An internal investigation will be conducted utilizing the resident incident report, the PB-22 form, interviews of resident, staff, and family members and description of the resident's injuries. All investigations will be conducted thoroughly and attempts to gather as much factual information as possible.

Review of admission record indicated Resident R48 was admitted to the facility on 10/17/24.

Review of Resident R48's Minimum Data Set (MDS - a periodic assessment of care needs) dated 2/19/25, indicated the diagnoses of anemia (low iron on the blood), heart failure (the heart can't pump blood as well as it should), and hypertension (high blood pressure). Section GG 5.E. Chair/bed-to-chair transfer is coded as 01, (01- indicating dependent).

Review of Resident R48's care plan initiated on 10/18/24, indicated:
Focus: The resident is to be transferred utilizing a front wheeled walker with assist x two.
Focus: I am at high risk for falls related to confusion, deconditioning, gait/balance problems, history of frequent falls and falling out of bed.

Review of incident note dated 5/3/25, at 1:30 a.m. indicated Nurse Aid (NA) informed writer that when she went to put the resident into bed the resident stated, "Watch my leg". NA then looked at the resident's legs and saw a skin tear on the residents lower left lateral leg. Earlier in the shift resident was in bed yelling so a different NA assisted the resident up and into her chair to bring her to the nurse's station at 9:00 p.m. Resident sat at the nurse's station and did not say anything. The resident started falling asleep and was assisted back to her room around 1:30 a.m. when skin tear was discovered. When asked what had happened resident said, "It happened when I got in my chair". Skin tear measures 3cm x 3cm and is in the shape of a triangle. Skin tear was cleansed with NSS, patted dry, 3 steri-strips applied, and covered with bordered gauze.

Review of undated facility provided skin impairment huddle indicates:
How was skin impairment acquired? During transfer was noted with a question mark (?).
Residents' description of incident: "when I got in my chair".
Immediate intervention initiated: cleansed, patted dry, applied steri-strips, covered with border gauze.

Review of undated, unsigned, typed interview investigation completed by Registered Nurse (RN) Employee E3 indicated resident stated watch my leg when she was transferred into bed around 1:30 a.m. due to falling asleep at nurse's station. Residents front of wheelchair faced the head of bed placing her left lower leg near bed frame during transfer. When resident was in bed NA lifted pant leg and noticed fresh blood to left lower leg and skin tear. Its likely resident obtained skin tear from rubbing against bed frame with transfer back into bed.

During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that Resident R48 was an assist of two for transfers, a high fall risk, and that Resident R48 was transferred with an assist of one back to bed and that the facility failed to make certain a resident was free from neglect by not following transfer orders.).

Review of admission record indicated Resident R260 was admitted to the facility on 10/1/24.

Review of Resident R260's MDS dated 10/4/24, indicated the diagnoses of arthritis (joint inflammation) Parkinson's (neurological condition that causes difficulty with movement), and depression. Section GG -F Toilet transfer: The ability to get on and off a toilet or commode is coded 88 (88 = Not attempted due to medical condition or safety concerns).

Review of physician orders dated 10/1/24, indicated activities/mobility: transfer with assist of two staff, no ambulation in room or corridor, safety devices bed and chair alarms, low bed to floor.

Review of Resident R260's care plan dated 10/1/24, Focus indicated high risk for falls, Interventions: Be sure my call light is within reach and encourage me to use it for assistance. I need prompt response to all request for assistance.
Focus: I have actual bowel incontinence related to decreased mobility. Interventions: Provide me with a bedpan or bedside commode as needed.

Review of R260 progress note dated 10/14/24, at 5:24 p.m. indicated Nurse Aid (NA) put resident on toilet and went to answer another call light. As this writer was walking to her room, I heard an alarm going off and went to answer it. Upon returning this writer heard resident yelling for help and rushed with NA to residents' room to observe resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Tylenol given for right side arm/shoulder pain. When this writer asked resident why she didn't pull call bell and get up off toilet she stated what does it matter. Notified RN to come to residents' room to assess for injuries' notified sister-in-law and DR. Able to move all extremities except her right arm, shoulder and wrist that she is complaining of hurting and unable to move. Resident was put in bed by staff. Neuro checks all within normal range. x-ray ordered, here at facility.

Review of the facility provided incident reported dated 10/15/24, indicated NA entered Resident R260's room and observed her standing at the toilet pulling her pants down to use bathroom as she was self-transferring. Resident stated that she needed to have a bowel movement and would take a long period of time on the toilet. Requested staff to leave the bathroom for privacy. Staff transferred to toilet and instructed to use call bell when she was ready, they would wait outside her bathroom door. Call bell cord placed in resident's hand. Another resident's alarm was sounding across the hallway. Staff immediately responded to alarm. Within a few minutes nurse entered residents' room (alarm that had been sounding) NA asked nurse to check on Resident R260 while they provided care to resident that had alarm sounding. As nurse was walking over to Resident R260's room, she heard her calling out for help. Observed resident outside bathroom door lying on her right side of her body yelling it hurts with her head pointing toward bathroom door. Registered Nurse called for assessment. Resident R260 complained of right arm pain, wrist and shoulder discomfort. Resident R260 was able to move left upper extremity (LUE), and bilateral lower extremities (BLE), range of motion (ROM) within normal limits (WNL). Staff performed blanket lift assist x 4 to bed. RN immobilized right arm and contacted resident representative to update. Stated that she did not want Resident R260 to be transferred to the hospital and requested mobile x-ray. Physician contacted and approved mobile x-ray to come to facility.

Review of Resident R260's mobile x-ray findings dated 10/14/24, at 5:59 p.m. indicated mobile x-ray completed impression right humerus no fracture, incidental fracture dislocation deformity of the elbow. Recommendation to follow up with a dedicated x-ray series of the right elbow.

Review of Resident R260's progress note dated 10/15/24, indicated physician was notified and orders to apply a sling and to follow up with orthopedics on 10/15/24. Facility called orthopedics and an appointment was scheduled for 10/15/24, orthopedics requested an x-ray to be obtained at the hospital one hour prior to appointment. The orthopedic physician called the facility and reported that Resident R260's right elbow is dislocated and they will send to the emergency room for sedation and to reset the elbow.

Review of Resident 260's hospital note dated 10/15/24, indicated x-ray of the right wrist shows a fracture of the distal radius, a fracture of the coronoid process and elbow dislocation. Using conscious sedation a reduction was completed. She was placed in a simple sling and wrist splint and advised to follow up with an orthopedic provider.

Review of Resident R260's progress notes indicated a follow up appointment was scheduled on 10/22/24, with orthopedics for elbow dislocation, elbow fracture, and wrist fracture.

During an interview completed on 5/14/25, at 12:33 p.m. the DON confirmed that resident R260 was an assist of two for transfers, a high fall risk, and that Resident R260 was left in the bathroom unattended resulting in a fall that caused a dislocation of right elbow, fracture of the distal radius and a fractured of the coronoid process of the ulna and the facility failed to make certain a resident was free from neglect.

28 Pa. Code 201.14(a) Responsibility of licensee.
28 Pa. Code 201.18(b)(1)(3) Management.
28 Pa. Code 211.10(d) Resident care policies.
28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.










 Plan of Correction - To be completed: 07/02/2025

1. R48 ERS submitted to DOH on 5/16/2025. R260 ERS submitted to DOH on 5/15/2025.
2. An audit will be conducted by NHA of incidents/accidents over past 30 days for possible neglect that have not been reported to DOH by 6/15/2025.
3. DON/ADON will be re-educated by NHA for Resident protection from abuse, neglect, mistreatment or exploitation policy. DON or designee will provide Clinical staff with education regarding providing the ordered level of assistance for resident transfers and also on supervision while residents are in the bathroom/alarm/call light response.
4. An audit will be completed by NHA for incidents/accidents to ensure any allegation of neglect is submitted to DOH 3 x a week x 2 weeks then weekly x 2 weeks. Results of the audits will be brought to the QAPI meeting for review

51.3 (g)(1-14) LICENSURE NOTIFICATION:State only Deficiency.
51.3 Notification

(g) For purposes of subsections (e)
and (f), events which seriously
compromise quality assurance and
patient safety include, but not
limited to the following:
(1) Deaths due to injuries, suicide
or unusual circumstances.
(2) Deaths due to malnutrition,
dehydration or sepsis.
(3) Deaths or serious injuries due
to a medication error.
(4) Elopements.
(5) Transfers to a hospital as a
result of injuries or accidents.
(6) Complaints of patient abuse,
whether or not confirmed by the
facility.
(7) Rape.
(8) Surgery performed on the wrong
patient or on the wrong body part.
(9) Hemolytic transfusion reaction.
(10) Infant abduction or infant
discharged to the wrong family.
(11) Significant disruption of
services due to disaster such as fire,
storm, flood or other occurrence.
(12) Notification of termination of
any services vital to continued safe
operation of the facility or the
health and safety of its patients and
personnel, including, but not limited
to, the anticipated or actual
termination of electric, gas, steam
heat, water, sewer and local exchange
of telephone service.
(13) Unlicensed practice of a
regulated profession.
(14) Receipt of a strike notice.

Observations:

Based on facility reports, and staff interviews it was determined that the facility failed to notify the Department of Health of two reportable events.

Findings include:

Review of the clinical record indicated Resident R57 was admitted to the facility on 11/23/20.

Review of Resident R57's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 4/8/25, indicated diagnoses of anemia (too little iron in the body causing fatigue), dementia (a group of symptoms that affects memory, thinking and interferes with daily life), and diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time)

Review of Resident R57's progress notes dated 9/19/24, at 3:44 p.m. indicated that resident's nephrostomy tube (a thin catheter inserted directly into the kidney to drain urine) was noted to be out (dislodged), moderate amount of drainage from site. Resident going to hospital.

Resident R106 was admitted to the facility on 1/22/25.

Resident R106's MDS dated 3/10/25, indicated the following diagnosis Unspecified Nondisplaced Fracture Of Second Cervical Vertebra Subsequent Encounter For Fracture With Routine Healing ( a cervical fracture often called a broken neck) , wandering (person becomes lost or confused), and unspecified dementia ( a condition where people lose the ability to think, remember, learn, make decisions and solve problems).

Review of facility documentation progress notes dated 3/13/25, indicated the following:

Staff came to unit at approximately 4:40 pm, to notify nursing staff that resident was in the kitchen area. Employee E14 Nurse Aide went down to the kitchen and redirected Resident R106 back to the unit. Resident R106 has been wandering throughout the building this entire shift. Resident R106 requires continuous redirection to stay out of other residents' rooms.

During an interview on 5/15/25, at 2:36 p.m. Director of Nursing confirmed that the facility did not report nephrostomy tube dislodgement incident that resulted in a hospital transfer, and failed to report an elopement to the Department of Health.







 Plan of Correction - To be completed: 07/02/2025

1. R106 ERS submitted to DOH on 5/16/2025. R57 ERS submitted to DOH 5/15/2025.
2. An audit will be completed by NHA for events which seriously compromise quality assurance and patient safety that have not been reported to the DOH over the past 30 days.
3. DON and ADON will receive re-education by NHA for notification to department of health requirements.
4. An audit will be completed by NHA with review of resident 24 hour reports for incidents that seriously compromise quality assurance and patient safety to ensure events are reported to the department of health 3 x a week x 2 weeks then weekly x 2 weeks. Results of the audits will be brought to the QAPI meeting for review

§ 201.14(a) LICENSURE Responsibility of licensee.:State only Deficiency.
(a) The licensee is responsible for meeting the minimum standards for the operation of a facility as set forth by the Department and by other Federal, State and local agencies responsible for the health and welfare of residents. This includes complying with all applicable Federal and State laws, and rules, regulations and orders issued by the Department and other Federal, State or local agencies.

Observations:

Based on state regulations, staff interview, and review of the facility's Infection Control Committee Meeting attendance records, it was determined that the facility failed to ensure all of the required nine multidisciplinary members were present at the Infection Control meetings (a community member and laboratory personnel).

Findings include:

Review of Act 52 (The Act of March 20, 2002, P.L. 154, No. 13), known as the Medical Care Availability and Reduction of Error (MCARE) Act, Chapter 4, Section 403(1) Infection Control plan states, "A health care facility... shall develop and implement an internal infection control plan that shall include... a multidisciplinary committee including representatives from each of the following if applicable to that specific health care facility." A review of the applicable members at infection control meetings includes medical staff, administration, laboratory personnel, nursing staff, pharmacy staff, physical plan personnel, patient safety officer, a community member, and a member of the infection control team.

Review of the facility's Infection Control (IC) Committee Meeting attendance log forms for quarter three July 2024, August 2024, and September 2024, failed to reveal that a community member was in attendance.

Review of the facility's Infection Control (IC) Committee Meeting attendance log forms for quarter four October 2024, November 2024, and December 2024, failed to reveal that a community member or laboratory personnel were in attendance.

During an interview on 5/15/25, at 11:26 a.m. the Director of Nursing (DON) confirmed that a community member was not in attendance for quarter three, and a community member and laboratory personnel were not in attendance for quarter four.




 Plan of Correction - To be completed: 07/02/2025

1. Community member and laboratory personnel will be given set dates and times of the quarterly infection control meeting by 6/2/2025.
2. Infection control committee will be re-educated by NHA to include responsibilities and attendance requirements of the members.
3. An audit will be completed by NHA/designee of member attendance at the Infection Control meetings.
4. Results of the audits will be brought to the QAPI meeting for review

§ 201.20(a)(2) LICENSURE Staff development.:State only Deficiency.
(2) Restorative nursing techniques.
Observations:

Based on a review of facility handbook, employee education records and staff interviews, it was determined that the facility failed to ensure that employees completed the required annual restorative nursing techniques education for five of five employees reviewed (Nurse Aide (NA) Employees E6, E7, E8, Licensed Practical Nurse (LPN) Employee E9, and Registered Nurse (RN) Employee E10).

Findings include:

Review of the "Quality Life Services Employee Handbook" dated 8/22/23, indicated in order to maintain the high degree of skill and ability necessary to ensure superior resident care, all employees are required to participate in mandatory or approved meetings, in-service training programs, and online courses.

Review of NA Employee E6's facility provided staff list indicated he was hired on 2/24/92. Review of NA Employee E6's training record did not include documentation on annual restorative nursing techniques.

Review of NA Employee E7's facility provided staff list indicated she was hired on 7/8/11. Review of NA Employee E7's training record did not include documentation on annual restorative nursing techniques.

Review of NA Employee E8's facility provided staff list indicated she was hired on 3/15/22. Review of NA Employee E8's training record did not include documentation on annual restorative nursing techniques.

Review of LPN Employee E9's facility provided staff list indicated she was hired on 8/24/20. Review of LPN Employee E9's training record did not include documentation on annual restorative nursing techniques.

Review of RN Employee E10's facility provided staff list indicated she was hired on 11/6/18. Review of RN Employee E10's training record did not include documentation on annual restorative nursing techniques.

During an interview on 5/15/25, at 1:18 p.m. Nursing Home Administrator confirmed that the facility failed to ensure that employees completed the required annual restorative nursing techniques education for five of five employees reviewed (NA Employees E6, E7, E8, LPN Employee E9, and RN Employee E10), as required.









 Plan of Correction - To be completed: 07/02/2025

1. Employees E6, E7, E8, E9, and E 10 were assigned the restorative nursing techniques education modules through the facility continuing education program.
2. Restorative Nursing Techniques education has been assigned to all clinical staff that have not completed it within the last 12 months.
3. Education provided by the NHA to the HR/staff development personnel regarding the required annual Restorative Nursing Techniques education for clinical staff at the time of orientation and annually.
4. Audit of completed annual restorative nursing techniques education will be completed monthly x 2 with the results reviewed and shared at the facility QAPI committee.


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